The No Surprises Act and Your Practice

It’s no secret that patients’ healthcare costs have been rising for years now. Between high deductible health plans and increasing premiums, medical debt is at an all-time high, causing stress for patients and difficulty with revenue for providers. It’s a large burden to carry, but one big weight, surprise bills for out-of-network services, is being relieved this year with the implementation of the No Surprises Act. It’s certainly good news for patients but will require some additional work on the part of providers. So, what do you need to do to comply with this law without losing revenue? Let’s take a look.

What is the No Surprises Act?

The No Surprises Act, now in effect as of January 1, 2022, seeks to relieve the burden of surprise medical bills from out-of-network providers by requiring disclosures that will allow patients to make a financially educated decision about their care. The law also requires that in emergency situations, providers not bill patients more than their responsibility would be for in-network service.

What does your practice need to do to comply?

When caring for patients for whom you are out-of-network, you will need to disclose a good faith estimate of the cost that patient can expect to incur for your services. This can be established using a patient cost estimation solution or by reaching out directly to the patient’s insurance payer. Once this estimate is determined, the provider must give written notice to the patient within 72 hours prior to the service, detailing that the provider is, in fact, out-of-network, what the cost estimate is, a listing of providers within the facility who are in-network, information on prior authorization and any other requirements, and a clear statement that the patient does not have to consent to the service at this cost and can choose an in-network provider instead if they wish. In cases when the patient can’t reasonably be expected to choose another provider or facility, this notice and consent process would not apply, and the patient would only be responsible for the amount that would apply if the service were being performed in-network.

In cases where the notice and consent process doesn’t apply, such as emergency services, diagnostic services, pathology, neonatology, radiology, and anesthesiology, it is up to the provider to work with the payer to submit a claim to receive payment. It’s worth noting that this payment may be perceived by the provider as too low, and in that case the provider is welcome to enter negotiations with the payer. The provider may not, however, bill the patient for anything beyond what their responsibility would have been were the provider in-network.

Arguably, providers will be affected by the No Surprises Act. It will certainly impact workflows and add steps where they didn’t exist before. It will likely impact revenue, more so if those added steps aren’t followed thoroughly. That being said, this law doesn’t have to spell disaster for your practice if you have the right partners. Under the No Surprises Act, one of the most important steps you can take is to provide an honest, accurate estimate during the notice and consent process, when applicable. To do this, you need to be able to efficiently obtain an accurate estimate of the patient’s responsibility. This is where MicroMD comes in. Our practice management system allows you to check patient insurance eligibility to accurately identify those patients for whom you are out-of-network. Pair our PM with one of our preferred clearinghouse partners, and you’ll have full patient responsibility estimate capabilities.

Ready to get started? Visit micromd.com or call 1-800-624-8832 for more information.

There’s a lot to learn when it comes to the No Surprises Act, and that’s why we held a webinar, along with Trizetto, focusing on the requirements laid out by this law. The recording of this webinar is available here.