Taking the Surprise Out of the No Surprises Act, Part 1

January 2022 rang in the new year with the No Surprises Act and it’s the hot topic in the industry right now. Over and over again, we’re hearing physicians nationwide ask the same questions, “What do I need to do?” and “How is this going to affect my practice?” 

With a penalty of up to $10,000 per violation, it’s clear why practice owners are trying to get ahead of this new legislation. 

What problem does this bill solve?

The No Surprises Act (NSA) intends to protect patients from receiving the surprise of an unexpectedly large bill in the mail after receiving medical care. 

According to this healthcare.com survey from 2021, over a third of Americans have received at least one surprising medical bill that left them in debt, even while holding valid health insurance.  At a time when we are at our most vulnerable, with people sometimes rationing their healthcare, receiving an astronomically large bill can feel like a double whammy.  Is this a problem? Absolutely. 

Why is the solution challenging?

Right now, there are several insurance payers in the industry and each has their own suite of plans which providers must fully understand and decipher in order to correctly determine eligibility. Unfortunately the result of this variety means it’s all too common for a provider to find themselves not signed up, or even eligible, for their intended coverages. This means that many providers, as they see patients, may not immediately know if they are participating in the correct suite of plans unless they call a patient’s insurance directly to verify. Providers already maintain a full clinic schedule traveling between multiple hospitals for inpatient rounds, and checking in with various facilities, making the typical workday jam packed and a lot of times unpredictable.

For a provider to timely treat patients in need of care, and to meet the requirements of this bill, providers will need to have that eligibility verified, provide patients with a cost estimate, and acquire that patient’s signature of approval for the provider they want to see (not someone else). That’s certainly a lot of steps that will require a thorough process to accommodate the unpredictability of a physician’s schedule and patient roster.

So what does the No Surprises Act change?

It puts an end to balance billing and requires providers to supply healthcare estimates prior to services. 

Balance billing is a practice in which patients are billed for the remainder balance of their healthcare claim when insurance doesn’t cover the costs, usually if the provider is considered out-of-network. With the NSA, providers will only be allowed to invoice and collect the in-network cost-sharing amount. 

For patients who are uninsured or decline to have their doctor bill their insurance, the NSA requires providers to provide Good Faith Estimates to these patients ahead of receiving care. This allows patients to go into their appointment knowing what the cost will be. 

There may be technical safeguards practices can implement within practice management and billing systems to satisfy these new requirements to avoid any unintentional balance billing; however, there is no guarantee such stopgap systems will catch all potential scenarios. For instance, practices can have staff review each appointment and claim against a checklist but that defeats the purpose of any investments  a practice has made in technology to take care of repetitive, labor intensive tasks. Developing a solution of both technical and people processes is the only way to tackle meeting the requirements of the No Surprises Act and ensuring your patients have the best healthcare experience.

Take the first step towards better results and schedule your free consultation.