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December 6, 2021

Guide to Surprise Billing Provisions in the Consolidated Appropriations Act 2021

December 6, 2021

It’s almost the end of 2021, which means it’s time to prepare for the policy changes going into effect for the following year. The biggest one to pay attention to is the No Surprises Act (NSA), part of a comprehensive COVID-19 relief package in the Consolidated Appropriations Act. This law becomes effective January 1, 2022, and may require some changes in your practice to stay compliant and save your bottom line. The NSA establishes greater price transparency, creates provider directories, and provides patient financial protections. These sound simple enough, but the Act has many ramifications for providers as well as health plans. In particular, anesthesiology providers, as anesthesiology procedures, account for a high number of surprise bills due to patients not choosing their anesthesiologist prior to services. Let’s take a look at some of the crucial provisions in this law that will affect your anesthesiology billing practice in the coming year. 


Price Transparency

Whether the procedure is in-network or out-of-network, there are new requirements to establish greater patient price transparency. If the provider is out-of-network for a patient at a facility, the procedure must be billed at in-network rates, and the patient cannot be balanced billed. There are exceptions to this rule, included in the notice and consent requirements in the NSA. 

Before obtaining the patient’s consent for treatment, an out-of-network provider must deliver to the patient a good faith estimated amount of billing for all expected services. This notice must be provided 72 hours in advance of the scheduled procedure, and it’s required that the patient is also notified of any in-network providers at the facility where the procedure is taking place.

Of course, this is not always possible regarding emergency services where anesthesiology is often utilized, and the NSA does allow provisions for these scenarios. There are penalties for violating the notice and consent requirements, so updating your practice’s standards accordingly is essential. 


Provider Directory

This is mostly more on the part of the health plans to keep their provider directories accurate for patients. However, there are still new rules regarding how often providers report their contract status to these directories. To keep provider directories accurate and updated, providers must submit new directory information when beginning an agreement with a network, when the provider terminates an agreement, or if there are any significant changes in your practice, i.e., a location change. 

Providers are required to update their status at least once every 90 days, even if no changes have occurred. This necessitates putting in place a process to communicate regularly with health plans. Suppose a patient utilizes your services based on old information because you neglect to update the health plans’ patient directory. In that case, the patient will only be responsible for in-network costs. Providers will be required to cover overages, and if a patient has already paid, the provider must reimburse with interest. 


Patient Financial Protections

The NSA protects patients receiving unanticipated out-of-network care from surprise medical bills, whether in an emergency or non-emergency setting. Patients are only responsible for cost-sharing at their in-network rate, and providers are barred from holding patients accountable for higher amounts.

If there is a dispute between plan, patient, and provider, the Act establishes a new process for resolving payment disputes. This Independent Dispute Resolution (IDR) process consists of a 30-day negotiation period during which a third entity is contracted to resolve disputes between the patient and provider. The patient must make an initial payment determined by the plan. If the provider is not satisfied, an IDR entity is contracted. The IDR entity considers both parties’ offers and other factors, including qualifying payment amounts in the same geographic region, levels of training and patient acuity, outcome measurements, and the scope of services offered at the facility. The party whose offer is not chosen by the IDR entity is responsible for the costs of the IDR.


The Bottom Line

The No Surprises Act is a law intended to protect patients from financial liability for surprise medical bills and establish a method for determining payments made by a patient's insurer to an out-of-network provider. In states where these laws have previously been enacted, the in-unit price for anesthesia dropped, despite the exceptions for anesthesiology services in the act. Thus, it’s crucial to stay on top of these changes to ensure you aren’t leaving any money on the table in your billing process or incurring further costs through violations and penalties. These changes protect patients, not necessarily plans and providers, so the provisions are important to pay attention to maintain your practice’s bottom line.


For a free anesthesia billing consultation, contact us today! 




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