NO SURPRISES ACT
The No Surprises Act is new legislation enacted by CMS. Parts of the Act went into effect January 1, 2022. The purpose of the Act is to protect patients from unknown costs of care and ensure patients have access to information to understand the true costs of healthcare services. The Act consists of two parts: 1) Independent Dispute Resolution (IDR) Portal and 2) Good Faith Estimates (GFE). In this newsletter, we will briefly break down those parts and their applicability to our organization.
IDR PORTAL
The purpose of this section is to prohibit balance billing at in-network
facilities by out-of-network providers. If a patient presents at a facility that
is covered by their insurance but one of the ancillary providers (i.e.
anesthesia) is not covered, that provider can no longer balance bill the
patient for costs not covered by their out-of-network insurance. The Act has
developed a process for payers and any out of network providers to resolve
any disputes for the claim amount. This portion of the Act has seen the most
controversy including lawsuits. The Act outlines factors to be considered by
the dispute resolution entity when determining the amount of the claim.
These factors are the qualifying payment amount; level of training,
experience, and quality and outcome measurements; market share; acuity of
patient; teaching status, case mix and scope of services; and the good faith
efforts to negotiate. CMS initially published a rule giving more weight to the
qualifying payment amount, but a Texas lawsuit found this rule to be an
inaccurate interpretation of the Act. All factors are now given equal weight
in the dispute process.
At this time SHA has not had any disputed claims. One reason for this is we
work diligently to maintain in-network status with payers that are in network at the facilities we serve. An out-of-network disputed claim while not impossible, will be a very rare situation for our organization.
GFEs
The purpose of this section is to provide uninsured and self-pay patients with
an estimate of the costs of care prior to a scheduled surgery. The convening
provider (i.e. the facility scheduling care) is required to provide a written
GFE to a patient upon request when the surgery or care is scheduled at least
3 days in advance. Co-providers, which includes anesthesia, will be required
to provide estimates for their services to the convening provider to include
in one written estimate beginning January 1, 2023. The enforcement of the
co-providers was delayed to allow convening providers the opportunity to
develop a system for establishing estimates. The estimate should include all
anticipated costs. If the surgery goes as expected, then the total billed
amount for all provider costs listed on the estimate should not exceed the
estimate by $400. If the bill is $400 more than the estimate, the patient can
dispute the bill. The burden will be on the provider to show why the costs
exceeded the estimate, but at a minimum the patient will be responsible for
the amount of the estimate.
SHA has been working diligently with our billing company to develop a
process for estimates. We have created spreadsheets referencing average
anticipated costs associated with different surgeries, including ultrasounds
and blocks. Additionally, we have had meetings with our facilities to
prepare our administrative teams to begin providing GFEs by the January 1,
2023, enforcement date.