Implementing the No Surprises Act from the Executive Level

No Surprises Act of 2022: Key aspects

In December 2020, as a method to reduce unexpected medical bills that many patients faced after receiving care, Congress passed the No Surprises Act. As a relatively new law, it was primarily designed with the intent to prevent the consumer or patient from getting hit with surprise bills upon receiving medical treatment.

Richard Cheng, Member Counsel, reported that the process of eliminating unexpected bills entails three major features:

• The No Surprises Act prevents the provider from submitting a bill in an attempt to collect the difference between their charges and what they actually received under the plan.
• It’s the provider's obligation to provide the patient with an estimate of the cost of a service.
• The dispute resolution process allows the patient or consumer to dispute substantial differences between the good faith estimate and the bill they received.

The responsibilities of the No Surprises Act for decision-makers

Decision makers play an integral role in dealing with the No Surprises Act as it is their responsibility to ensure that their practice is compliant with each of the rules that the law consists of. The coordination process of delivering good faith estimates involves an array of actors as every phase of the revenue cycle is impacted.

Alpha II’s Chief Product and Strategy Officer, Adam Seymour, sheds light on this by suggesting that one of the most important responsibilities of decision-makers is “to ensure that all departments are aligned as this is not an issue that can be managed within a single department,” says Seymour. Ensuring that payers are meeting their end of the obligations as well as ensuring balanced billing is only occurring when appropriate are examples of other important responsibilities that should be prioritized by decision-makers.

Greenway Health’s Chief Product and Technology Officer, David Cohen points out that any healthcare professional needs to ensure that they have a thorough understanding of the regulations to make adjustments to their normal workflows, especially regarding good faith estimates.

Cohen goes on to suggest that “managing certain aspects of a pre-visit experience that may have typically been taken care of post-visit,” and “the need to electronically provide estimates 72 hours in advance of a visit,“ are additional examples of how the law may change normal procedures within organizations moving forward.

Potential repercussions for not implementing the No Surprises Act into revenue cycle management workflows

So far, enforcement of the No Surprises Act has yet to begin in earnest; however, Seymour believes that all stakeholders should be prepared for this sooner rather than later. He says that going into 2023, “states will play a primary role in many cases, but the federal government can step in to impose penalties up to $10,000 per incident of cases where there was improper balance billing or misuse of the waiver and exception conditions,” adding that “revenue leakage is another key concern in this regard.”

Other examples of situations that can result in a major impact that providers should be aware of:

• Failure to provide reasonably accurate good faith estimates.
• Failure to monitor how payers are handling out-of-network situations by making sure payers are fulfilling their obligations.

In situations where a good faith estimate is underestimated, patients can reach out to file a complaint with the CMS. From there the complaint is then referred to the Selected Dispute Resolution entity (SDR), which notifies the provider about the complaint and allocates 10 days for the provider to respond with a reasonable explanation for each of the charges included in the good faith estimate.

“If the provider is successful in this explanation, the SDR will allow them to move forward with their collection efforts. However, if the provider is unsuccessful, and the patient’s claim prevails, the SDR will then guide on what the final cost should be based on the viability of the excess charges,” describes Christopher Reed, Weaver Johnston Nelson’s Senior Counsel.

Solutions to ease the transition and ensure compliance with the No Surprises Act of 2022

Fortunately, providers such as Greenway Health and Alpha II work as advisors and consultants for their clients to provide them with robust solutions. Implementing technology platforms to help standardize workflows and document process changes helps providers efficiently communicate and share information with their patients.

Technologies including EHRs (Electronic Health Records) and PM (Practice Management) are important in ensuring that all practices are adhering to and complying with legislation such as the No Surprises Act. Using an example, Cohen says “patient information must be clearly understood and captured pre-visit and documented in a PM solution as a way to determine all necessary care and adjustments that are necessary for calculating a good faith estimate.” To do this, making technology alterations within products may be necessary to best support and align with new organizational processes regarding No Surprises Act requirements.

Requirements such as good faith estimates must be communicated and disclosed to patients with transparency at all times. With this in mind, Greenway is specifically leveraging patient engagement platforms such as patient portals and secure messaging technologies and solutions to safely transmit and store good faith estimates inside of PM solutions.