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No Surprises Act: Out-of-Network Providers at In-Network Facilities, Part 2

This part 2 of our No Surprises Act series is the next installment from last week’s post.

When looking at what healthcare insurance covers, or doesn’t cover, patients typically will see both in-network and out-of-network prices.  Using their healthcare plan’s tools, patients can generally check and see what providers and facilities are considered in-network to make an informed decision and decrease their costs out of pocket. However, there is a catch. A patient can be in-network at the facility but out-of-network with one of the many providers that see that patient. 

The No Surprises Act (NSA) addresses the situation of what happens when an out-of-network provider sees a patient in an in-network facility. 

Thankfully, the burden does not fall entirely on physicians, the NSA does have rules for the healthcare plans to do their part. In fact, insurance companies have 30 days to make a payment after receiving an insurance claim from the practice and are subject to a 30 day negotiation window if the provider does not agree with the payment amount. However this means within those 30 days, providers will be waiting on mail delivery and accurate payment posting before determining if they would like to negotiate the rate. The result of this process will force practices to be diligent about posting lag and patient billing practices. 

Ultimately this means providers are only allowed to bill the patient for the in-network cost-sharing in this case if they have the patient sign a consent form to allow the for balance billing AND the services do not fall under the listing of the situations where providers are never permitted to balance bill. 

If a practice does have the patient sign a consent form and the services are eligible for balance billing, providers may need to indicate on the insurance claims that services were performed at an in-network facility and provide a copy of the signed consent with the claim submission. For patient invoices, providers may need to also send copies of the consent form with the bill to the patient. 

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