Surprise Billing in Healthcare: The No Surprises Act Takes a Stand for Patients

On January 1, 2022, Requirements Related to Surprise Billing;PartsI andIIunder Title I, theNo Surprises Act, will take effect. These rules lay the groundwork to protect patients against surprise billing in healthcare and promoteprice transparency. The Departments ofHealth and Human Services (HHS),Labor, andTreasury, along with the Office of Personnel Management (OPM), will issue the No Surprises Act legislation, which impacts healthcare providers and facilities, ambulance services, group health plans, health insurance issuers, andFederal Employees Health Benefitsprogram carriers.

Fighting Surprise Billing in Healthcare: The Background and Purpose of the No Surprises Act

当病人在不知情的情况下从网络外的提供者那里获得医疗服务时，就会发生意外账单。这种相互作用导致医疗服务的价格更高，如果由患者健康计划网络内的提供者提供，则会更便宜。在紧急情况下，响应小组通常会将患者送到最近的急诊室，无论该机构是否在网络内。

Even when a patient chooses an in-network facility in a non-emergent situation, they usually don’t realize if a provider involved in their care is out of network (e.g., an anesthesiologist or radiologist). These situations tend to lead to a transaction known as “balance billing,” in which the out-of-network provider bills the patient for the difference between the charge and the amount the patient’s insurance paid. Because the patient doesn’t have the option to choose an in-network provider in these cases, the expense is typically unexpected and unmanageable.

传统上，医疗服务提供者会直接向网络外的病人收取服务费用。提供者和患者的保险公司没有任何合同协议，让患者和保险公司来解决支付纠纷。According to the Centers for Medicare and Medicaid Services (CMS), in 2016, 42.8 percentof emergency room bills resulted in out-of-network charges, even when a visit was to an in-network hospital. While Medicare and Medicaid both prohibit the use of balance billing, commercial and employer-sponsored plans do not.

《无意外法案》旨在建立新的保护措施，防止医疗保健中的意外账单和病人接受医疗保健服务的过度成本分担。自2022年1月1日起，网外计费流程将从患者转向供应商。这一转变旨在消除患者意外开药的负担。

What Does the No Surprises Act Mean for Providers?

为了遵守该法案，提供商将需要对流程进行一些重大调整。Working withpayersrather than patients for payment will be a new practice for many providers. For emergency out-of-network cases and out-of-network providers seen at an in-network facility (such as anesthesiologists and radiologists), the Act will limit patient billing to an amount no greater than the patient’s in-network obligation according to their insurance plan.

Because out-of-network providers don’t typically have established contract rates with insurance companies, the Act will require to provider to bill the health insurance first to see if services are covered under the patient’s specific plan. The Act requires insurance companies to first check if there is an applicableAll-Payer Model Agreementundersection 1115 of the Social Security Act或者如果有一个州的法律决定了网络外服务的总费用。在州法律的情况下，该法案从州法律金额计算成本分担。

For example, if the patient’s obligation is 20 percent for an in-network provider, the plan could take the state law amount allowed for that medical service and require 20 percent of that amount from the patient. If there is not an All-Payer Model Agreement or law, insurance companies must calculate the median in-network payment for that medical service based on their contracts with other providers within the same geographic region. The No Surprises refers to this metric as the qualifying payment amount (QPA).

Once the out-of-network provider receives an initial payment or denial notice from the insurance plan, the provider has two choices:

• 接受初始付款加上网络内患者费用分摊额作为全额付款。
• Engage in direct negotiation with the insurance company.

Negotiating or Resolving Payment

The Act allows 30 days for providers and insurance companies to negotiate payment. If the negotiation is unsuccessful, either party can initiate theIndependent Dispute Resolution (IDR)process. Under the IDR, the parties jointly select a certified independent dispute resolution entity who has no conflicts of interest with either party to resolve the dispute. If the parties can’t agree on a certified independent dispute resolution entity, the Departments (HHS, Labor, Treasury, and the OPM) will select one.

Both parties will then submit their offer representing the cost they think the plan should pay for the services provided, along with supporting documentation. The certified dispute resolution entity will issue a binding determination.

Notably, not all services are eligible for the IDR process. This process applies only to those services for which balance billing was prohibited in Part I of the Requirements Related to Surprise Billing rule. Each step of this process will require new internal processes—providers need to begin planning for these promptly.

The Exception to the Rule: Patient Notice and Consent

该法案允许，在有限的情况下，提供者或机构通知患者有关潜在的网络外护理和费用，并在治疗前获得同意。这一要求将允许医疗服务提供者向患者收取网络外费用分摊额，并向患者支付保险计划允许金额与医疗服务提供者收费之间的差额。

The Act does not specify for what types of cases it will allow out-of-network notice to the patient. However, it specifically states that providers or facilities should not use the exception for services that are common surprise billing situations, such as emergency services and certain ancillary services. As the Departments haven’t yet specified the type of services for which they will allow a notice and consent, providers must watch for further guidance.

The Act also requires certain providers and facilities to make publicly available, post on a public website, and provide patients with a one-page notice on patients’ rights with respect to balance billing. The notice must contain the requirements established under the Act, any state-level protection laws, and contact information for state and federal agencies to report any potential violations.

The Good Faith Estimate: Price Transparency

One thing all providers—even those who are likely to be in network—need to note is the Act’s new requirements regarding price transparency. The rule will require all providers to reach out to patients prior to a scheduled appointment to solicit the patient’s insurance information and then issue aGood Faith Estimate对病人的保险计划。

该估计应包括将提供的服务的描述和提供商的估计费用。The insurance plan must then send the patient anAdvance Explanation of Benefits(EOB) at least three days prior to the appointment.

The advanced EOB should include the following information:

• 要提供的服务的描述，无论提供者是在网络内还是在网络外。
• The contracted rate for services (if the provider is in network).
• A description of how to access in network care (if the provider is out of network).
• The provider’s estimate of charges and the patient’s responsibility total.
• 病人关于免赔额和自付最高限额的状态。

Insurance plans must provide patients with an up-to-date directory of in-network providers, an insurance card that describes the deductibles and out-of-pocket maximum limitations for in- and out-of-network providers, and a price comparison tool.

If the patient is uninsured (or self-pay), the provider must provide the Good Faith Estimate directly to the patient within a specific timeline: The Act states that if the patient schedules the services at least three days prior to the appointment date, the provider must offer the estimate within one business day after scheduling. If the patient schedules the services at least 10 days before the appointment date, the provider must share the estimate within three days of scheduling.

Balancing Burden to Providers with Benefit to Patients

Most providers consider protecting patients from unexpected and unmanageable medical bills an important part of patient care. However, these process changes will take time and effort to implement. If providers do not prepare, they may experience delays in payment and financial penalties for noncompliance. The No Surprises Act’s ultimate goal is price transparency, which most providers agree improves the patient experience and increases the likelihood of payment for care.

Additional Reading

Would you like to learn more about this topic? Here are some articles we suggest:

• Healthcare Price Transparency: Three Opportunities for Transformation
• Healthcare Financial Recovery: A Guide to the COVID-19 Add-On Payment
• The Prior Authorization Process: Need-to-Know Changes for 2021
• How Regulatory Compliance Supports Optimal Patient Care and Higher Earnings
• Healthcare Price Transparency: Understanding the Cost-Pricing Relationship

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