The No Surprises Act (NSA) is not just a pointless consumer protection law - it’s congress’s earnest attempt to safeguard individual beneficiaries from unexpectedly high medical bills. The need for this legislation became evident in the wake of COVID-19 hospitalizations as emergency, and out-of-network payments spun out of control. Learn more about the No Surprises Act here!
The Interim Rules of the NSA established the ‘what’ ‘when’ and ‘why’ of this Act, and this Final Rule (FR) lays out the ‘how.’ The Final Rule establishes the compliance procedures and enforcement provisions that will back up the NSA. The grace period is over on January 1, 2022, so make sure you are familiar with the changes this will necessitate in the billing logistics of your practice. The Final Rule sets up three major provisions:
Independent Dispute Resolution
In certain situations where the No Surprises Act prohibits surprise billing, there will be a conflict in determining the final payment allowable beyond the standard patient cost-sharing. This provision goes into effect if the 30-day “open negotiation period” between the out-of-network providers or facility and health plans or issuers doesn’t have a successful outcome. Both parties choose a “certified independent dispute resolution entity” that will select the appropriate Qualifying Payment Amount (QPA) for this final payment. This is a federal arbitration process for which both parties must pay an administrative fee ($50).
Good Faith Estimates
The second provision of the Final Rule is almost a preventative method, intended in the case of non-emergency services provided to uninsured and self-pay patients. This provision stipulates that beneficiaries must receive accurate cost estimates before a procedure to receive informed care. This ensures that most cases don’t make it to the dispute resolution process. A good faith estimate encompasses the costs of what can reasonably be expected during a procedure. For surgery, a good faith estimate should include the cost of the procedure, any labs or tests, and the anesthesia to be used during the operation. It excludes any post-operative care, prescription costs, or physical therapy. Typically the facilities or primary providers create these good faith estimates. That doesn’t mean anesthesia providers are off the hook, though. You can’t expect a facility to know all the intricacies of the anesthesia required for the procedure, so double-check their work. Don’t leave your fees up to the facility to report.
Patient-Provider Dispute Process
If there is no health plan or issuer to act on behalf of the beneficiary, the third provision of the Final Rule authorizes a direct patient-provider dispute process. This process is normally invoked in the case of uninsured or self-pay individuals. In this case, patient bills that are substantially in excess of the good faith estimate enter into a dispute process for resolution. The good faith estimate is very important, because this dispute process only covers bills that are $400 or more over the estimate. Further, this process must be initiated within 120 days after the patient receives the bill. All these provisions in the Final Rule protect medical beneficiaries from going into bankruptcy over unexpected or surprise medical bills.
How Does this Affect Anesthesiology Providers?
The enforcement provisions for the Final Rule have a similar structure over providers to that established by the ACA. Compliance is monitored at the state level. Unless it’s not adequate, then the federal arbitration process becomes involved. The sum impact of the processes laid out in the No Surprises Act is that it will become more difficult for service providers and physicians to negotiate fair payments for out-of-network services. This especially includes anesthesiology providers, as the facility may be in-network for a certain procedure, but the anesthesiologist may not be. Health plans, as of now, have minimal incentive to offer fair contracted rates, and the No Surprises Act will also make it more difficult for providers and physicians to have meaningful contract negotiations with them.
If you have more questions or concerns about the No Surprises Act and how it will affect your business, reach out to us here.
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