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Because of the new requirements and unanswered questions from healthcare organizations surrounding this Act, SpinSci is breaking down key points your organization needs to know to effectively manage the regulation.
What is the No Surprises Act and why is it a thing?
The No Surprises Act prevents patients and healthcare consumers from receiving “surprise” bills or bills that were not disclosed to them before receiving medical care. This act falls under the Consolidated Appropriations Act of 2021 which was enacted on December 27th, 2020 in response to COVID-19 healthcare responses.
Let’s consider a patient who needs emergency care. Our patient has a bad car wreck but is thankfully conscious enough to choose care from an in-network hospital. The patient arrives at the hospital, is told they need surgery, and immediately consents to life-saving care. The “surprise” can be needing an out-of-network service during this emergency surgery. This could be from an out-of-network contracted specialist surgeon or an out-of-network piece of equipment. Were these resources expected in a routine emergency surgery? Not necessarily. Is the healthcare organization expected to stop the surgery, wake the patient up, and confirm their insurance coverage before moving forward with this life-saving care? From a medical perspective, definitely not.
The Centers for Medicare and Medicaid Services (CMS) says the above example happens more commonly than the average healthcare consumer would hope. The Kaiser Foundation discovered that this occurs with nearly 20% of all emergency room visits. Despite best efforts to receive in-network coverage, the consumer is left with a “balance bill” where the consumer pays the difference between the charges billed and the amount actually paid by the consumer’s coverage. This is one “surprise” no patient wants to receive, and the imbalance of who now foots the bill is a “surprise” no healthcare organization wants.
Will the No Surprises Act affect your healthcare organization?
The No Surprises Act applies to all healthcare settings regardless of required service or health specialty with only a few limited exceptions. It also applies to most patients, including those who are uninsured or self-pay. Notably, patients enrolled in federal insurance programs, like Medicare or Veterans Affairs, will not be affected by this Act.
Who pays now?
Short answer? It depends on your state’s laws.
Based on the No Surprises Act interim final rules, cost-sharing of out-of-network services can be calculated by your organization using one of the following three ways:
- An amount determined by your state’s all-payer model agreement OR
- An amount determined by an existing and applicable state law, provided the state does not have an all-payer model agreement OR
- An amount equal to the lowest of either the qualifying payment amount or the billed charge for services, in the event that there is no state all-payer model or applicable state law
Need more detail? CMS published this helpful fact sheet on the most recent comments delivered to the Department of Health and Human Services (HHS), the Department of Labor, and the Department of the Treasury prior to September 2021.
So what does my healthcare organization need to do in order to comply with the No Surprises Act?
The No Surprises Act requires both providers and third-party payers to make significant changes in how they interact with and bill their patients.
Healthcare organizations will need to ensure adequate disclosure of necessary and potential healthcare services for that patient’s care request. Disclaimers for out-of-network costs or “good faith estimates” will need to be the norm in patient disclosure paperwork. Patients also need to be given the option to voluntarily waive their No Surprises Act billing protections. All of this needs to be provided within 72 hours of scheduled out-of-network services or 3 hours for same-day services. Standard documents from HHS can be used by your organization.
New billing processes will need to be developed for most organizations, especially those that provide emergency services, post-stabilization services, and other unforeseen yet urgent medical needs.
How can SpinSci help your organization and your patients avoid “Surprises”?
SpinSci Technologies can assist your organization comply with the No Surprises Act in several ways. Check out some of our solutions:
- The moment a patient calls you to establish an appointment, our Patient Assist solution is there to immediately provide up-to-date information on a patient’s past claims and billing information so that your customer service team knows immediately what services are in- or out-of-network for that individual patient. We pride our innovative patient authentication technology in giving your organization and your consumers ease of mind.
- When it’s time for the patient’s appointment, our Patient Notify solution can be used to send out disclosure paperwork for the patient’s anticipated services within the 72-hr window now required by the No Surprises Act. Your patients can fill out these disclosures electronically and at their own pace, allowing your team the time to answer any questions they may have about potential charges.
- As healthcare organizations develop new best billing processes for their offered services, our Patient Engage solution empowers your patients to address their bill in whichever personalized manner they need as healthcare consumers. Omni-channel self-service options through voice, text, or chat functions allow both ease for the patient and for your staff in addressing concerns for emergent and unforeseen care as quickly as possible.
Want to learn more about how we can help?
Request a demo of our products, and we will connect you with a SpinSci Technologies team member.
