No Surprises Act Regulations and Patient Protections

The No Surprises Act Regulations are designed to protect patients from surprise medical bills, which can be overwhelming and financially devastating.

The Act requires that patients receive an estimate of the costs for any medical service or procedure 72 hours in advance.

This estimate must be provided in writing, including a good faith estimate of the total amount the patient will be expected to pay.

The estimated cost must also include any out-of-network charges, which can be a major concern for patients.

Effective January 1, 2022, group health plans and insurance companies are required to notify members about their rights and protections related to surprise medical billing.

This notice must be publicly available, posted on the group health plan's or insurance company's public website, and included on member Explanation of Benefits (EOB). Medical Mutual will use the Department of Labor's model notice for guidance.

Starting January 1, 2022, electronic EOBs will include this notice at the bottom of the document, and printed EOBs will have a scannable QR code that members can use to access the required information online.

The Transparency in Coverage (TIC) rule, finalized in late 2020, requires health insurers and group health plans to make health plan pricing information accessible to consumers, allowing for easy comparison shopping.

Data in machine-readable files must be updated monthly, but enforcement on these changes has been delayed at this time.

Medical Mutual is already working to ensure they're fully compliant with the TIC rule.

Insurers and group health plans must create and publish machine-readable files with rate information per the Transparency in Coverage (TIC) rule, starting July 1, 2022.

These files will be updated monthly and include negotiated rates for all in-network providers, and allowed amounts and historical billed charges for out-of-network providers.

Medical Mutual has made these files available for their active plans, and they can be found online.

The files are intended for technical analysis rather than consumer decision-making, due to the complex required format and methodologies used to capture the data.

Medical Mutual is also enhancing their cost estimator tool on My Health Plan, which can be used by members to compare costs of procedures and services by network providers.

Machine-Readable Files (In/Out-of-Network) are required by law for insurers and group health plans to create and publish rate information. Starting July 1, 2022, these files will be available for active plans.

You can find the Machine-Readable File for Medical Mutual's active plans on their website. These files will be updated monthly.

The files include negotiated rates for in-network providers and allowed amounts and historical billed charges for out-of-network providers. Due to the complex format, these files are intended for technical analysis rather than consumer decision-making.

Medical Mutual has a cost estimator tool on My Health Plan to compare costs of procedures and services by network providers. A new version of this tool will be available starting January 1, 2023.

These files may have different methodologies than other payers, so be aware of the potential differences.

The Consolidated Appropriations Act (CAA) and Transparency in Coverage (TIC) rule require that insurers and group health plans offer price comparison information to members via a web-based cost-transparency tool.

This tool must allow enrollees to compare costs across participating providers in a geographic region for specific items and services. It must also show members the amount they would be responsible for paying (cost-share) for having a specific service or item done by a specified provider.

The CAA and TIC rules were originally published with different target dates for making the cost transparency tool available, but a recent update has aligned the rules so that they both require the tool be online by 2023.

Medical Mutual, a health insurance company, supports price and quality transparency for consumers and has been proactive in offering a web and mobile tool that allows members to review price and quality of care information online. This information can also be provided over the phone.

By 2023, Medical Mutual will meet the TIC and CAA customer price transparency tool requirements, and will also make the tool available to the members of its self-funded clients.

Surprise billing can be a nightmare for patients who receive unexpected medical bills. In fact, emergency services must now be treated on an in-network basis without prior authorization, starting January 1, 2022.

Patient cost-sharing for emergency services cannot be higher than if the services were provided by an in-network provider. This means that any "balance billing" of costs in excess of the recognized in-network rate and/or cost-sharing is prohibited.

The No Surprises Act has implemented several key regulations to protect patients from surprise billing. One of these regulations requires providers to give good faith estimates (GFEs) to uninsured or self-pay individuals within a certain timeframe.

For example, if a patient schedules care at least three business days in advance, the provider must provide the GFE within one business day after the date of scheduling. If the patient is window shopping for care, the GFE must be provided within three business days of scheduling.

Here are the key requirements for GFEs:

Starting January 1, 2022, insurers and self-funded health plans are required to provide up-to-date provider directories on their public-facing websites. This is a significant change, as it ensures that patients have access to the most current information about their healthcare providers.

Health plans must verify the accuracy of provider or facility information at least every 90 days. This is a much more frequent update cycle than the traditional bi-annual publication schedule.

Providers must attest to their data every 90 days, and health plans must follow established guidance to remove providers who fail to do so from the directory. This process helps maintain the accuracy and reliability of provider directories.

Here's a summary of the key requirements:

Health plans must also update directory changes within two business days of submittal by the provider or facility. This ensures that patients have access to the most current information about their healthcare providers.

The No Surprises Act introduced several key changes to surprise billing regulations, building on the initial requirements outlined in Part I. One significant addition was the federal IDR process, which allows out-of-network providers, facilities, and plans to initiate a payment dispute resolution process.

This process is triggered when an out-of-network provider or facility is unable to reach an agreement with the plan or patient on a payment amount after a 30-day negotiation period. The federal IDR process is designed to provide a fair and transparent method for resolving payment disputes.

Here are the key details of the federal IDR process:

The federal IDR process also expands the scope of adverse benefit determinations eligible for external review to include determinations related to surprise billing and cost-sharing protections under the No Surprises Act. This means that patients who are unhappy with the payment amount determined by the IDR process can appeal the decision to an external review entity.

Independent Dispute Resolution is a process that brings in a third-party to determine the final payment amount in case providers and insurers/health plans fail to reach an agreement. This process is required by the No Surprises Act (NSA) legislation.

The IDR process involves the provider or facility and the health plan submitting a payment offer to the IDR entity, who will then determine the final payment amount. Both parties agree to accept this amount as final. Payment must be made within 30 business days of the decision.

Medical Mutual has partnered with Zelis to support this process, managing the payment dispute arbitration on their behalf. This helps ensure a smooth and efficient resolution to payment disputes.

The No Surprises Act provides important protections for consumers who obtain their health coverage through an employer, federal or state-based marketplaces, or an individual market health insurance issuer.

To ensure you're aware of these protections, you'll receive a Model Disclosure Notice for the No Surprises Act, which will outline your rights and responsibilities.

A Standard Notice and Consent Form For Patient Waiver of NSA Protections is also required, which will explain the process for waiving your protections.

You have the right to receive a Good Faith Estimate (GFE) from your healthcare provider, which is a detailed breakdown of the expected costs for your care.

A Model Good Faith Estimate (GFE) Form is available, which will help guide your healthcare provider in providing this estimate.

To help you navigate these protections, here's a quick summary of your rights:

Independent Dispute Resolution (IDR) is a process designed to resolve payment disputes between providers and health plans. It brings in a third-party entity to determine the final payment amount.

The IDR process involves the provider or facility and the health plan submitting a payment offer to the IDR entity, agreeing to accept the final payment amount as determined by the IDR entity. This ensures a fair and impartial resolution.

Payment must be made within 30 business days of the decision. Medical Mutual has chosen to partner with Zelis to support this process, which will manage the payment dispute arbitration process on their behalf.

Here's a step-by-step breakdown of the IDR process:

A gap analysis is essential to understand how your organization's processes align with the No Surprises Act requirements. This analysis will help you identify areas that need improvement and create a plan to become compliant.

The act has far-reaching implications that extend beyond revenue cycle, impacting various aspects of your organization, including marketing and communications, provider relations, patient experience, contracting, scheduling, operating rooms, supply chain, and IT.

To conduct a thorough gap analysis, consider the types of organizations affected by the act, such as freestanding ERs, freestanding urgent care centers licensed to provide emergency services, and private practices.

A well-communicated, carefully thought-out, and actionable plan is crucial to ensure compliance with the act's requirements, which take effect on January 1, 2022.

Here are some key areas to focus on during your gap analysis:

Differentiating between uninsured/self-pay and out-of-network (OON) patients is crucial for healthcare organizations to navigate the No Surprises Act's protections.

Insured patients with scheduled non-emergency services can complete a written consent form prior to the date of service with OON providers as a waiver to the No Surprises Act’s protections, but this isn't applicable to uninsured patients.

Organizations must think through their internal process workflows to differentiate between patient insurance status.

The workflow consideration extends to the processing of final patient bills, where electronic medical records (EMR) can be leveraged to better identify and scrub OON patient accounts for manual review.

Policies and procedures should be reviewed and updated to reflect process changes, as organizations adapt to the new regulations.

The Government and Compliance section of the No Surprises Act regulations is crucial to understand. The Centers for Medicare and Medicaid Services (CMS) plays a key role in implementing this law, and their website is a great resource for more information: https://www.cms.gov/nosurprises.

The U.S. Department of Labor is also involved in enforcing this law, and their website provides additional guidance: https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/no-surprises-act.

The government plays a crucial role in shaping healthcare regulations, and understanding their stance on compliance is essential for healthcare providers. The Centers for Medicare and Medicaid Services (CMS) has a dedicated webpage for the No Surprises Act at https://www.cms.gov/nosurprises.

To stay up-to-date with the latest regulations, you can visit the U.S. Department of Labor's website at https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/no-surprises-act. This website provides a wealth of information on the No Surprises Act and its implications for healthcare providers.

The No Surprises Act is a federal law that aims to protect patients from surprise medical bills. According to the law, healthcare providers must provide patients with clear information about their billing practices and any potential out-of-network charges. The law is enforced by the Department of Labor, which has a specific section dedicated to the No Surprises Act on their website.

Here are some key resources for healthcare providers to stay compliant with the No Surprises Act:

On September 16, 2021, the Notice of Proposed Rulemaking (NPRM) was issued to implement certain provisions of the No Surprises Act.

This proposed rule would establish new reporting requirements regarding air ambulance services, which is a significant aspect of the No Surprises Act. The NPRM also introduces new disclosures and reporting requirements regarding agent and broker compensation.

The proposed rule would require providers, health care facilities, and providers of air ambulance services to comply with new procedures for enforcement of Public Health Service Act (PHS Act) provisions. This would involve new disclosure and reporting requirements applicable to issuers of individual health insurance coverage and short-term, limited-duration insurance regarding agent and broker compensation.

The public comment period for the NPRM ended on October 18, 2021, providing stakeholders with an opportunity to provide feedback on the proposed rule.

Here are the key aspects of the proposed rule:

As of January 1, 2022, emergency services must be treated on an in-network basis without requirements for prior authorization. This means that if you need emergency services, you won't be asked to get pre-approval first.

Emergency services provided by out-of-network providers will be treated as in-network services, and you won't be charged more for them. In fact, any cost-sharing obligation must be based on in-network provider rates.

Here are some key points to keep in mind:

These changes are designed to protect patients from surprise medical bills, and to ensure that they're not charged exorbitant fees for emergency services.

The No Surprises Act requires healthcare facilities to provide a good faith estimate of expected charges. This estimate must be provided to uninsured and self-pay patients by January 1, 2022.

It's also a good idea to make a good faith practice run for the insured patient population, as they usually represent the majority of patients served.

To aid compliance, CMS released 11 documents, including a model form for good faith estimate of expected charges. Facilities should inventory the depth and breadth of services that require good faith estimates and develop clear communication with providers for timely and accurate estimates.

Patient cost-sharing is also a key aspect of the No Surprises Act. For emergency services, patient payments are limited to their cost-sharing and deductible requirements for in-network care. This means that if a patient's health plan has a 20% coinsurance requirement for in-network emergency care, that same 20% requirement applies to out-of-network emergency care.

The Qualified Payment Amount (QPA) plays a crucial role in patient cost-sharing calculations. The QPA is the median of the contracted rates recognized by the health plan on January 31, 2019, for the same or similar item or service provided by a similar provider in the same geographic region and indexed for inflation.

Here's a summary of the QPA and patient cost-sharing process:

Member ID Cards are getting an update to comply with new laws. The No Surprises Act requires health insurance plans to include certain information on ID cards, such as medical deductibles and out-of-pocket amounts.

You'll be able to find this information on the front of your ID card, along with a telephone number and website to seek assistance. Medical Mutual has already modified our member ID cards to meet these requirements.

New ID cards will be issued to all members before the end of 2022, and they'll be available in both physical and electronic versions. You'll receive a new card when your group renews or makes benefit changes, or at the end of your plan year month if you're not making any changes.

Here are some key details about the new ID cards:

Once you receive your new ID card, be sure to destroy your old one and start using the new one right away.

A good faith estimate is a crucial document that helps patients understand their expected costs for medical services. It's a requirement under the No Surprises Act, which went into effect on January 1, 2022, for uninsured and self-pay patients.

To provide a quality good faith estimate, facilities should inventory the depth and breadth of services that would require one. This will help ensure that patients receive accurate and timely estimates.

Developing clear communication and a common understanding with providers is essential for good faith estimates. This will help facilities coordinate the final bill to ensure it doesn't exceed $400 of the estimate.

Facilities should make a good faith practice run for the insured patient population, as they usually represent the majority of the population served.

Patient cost-sharing is a crucial aspect of healthcare billing, and understanding how it works can help you navigate the process more smoothly.

For emergency services, patient payments are limited to their cost-sharing and deductible requirements for in-network care.

If a patient's health plan has a 20% coinsurance requirement for in-network emergency care, that same 20% requirement applies to out-of-network emergency care.

Patient cost-sharing calculations are applied to the lesser of the facility or provider's billed amount or the Qualified Payment Amount (QPA).

The QPA is the median of the contracted rates recognized by the health plan on January 31, 2019, for the same or similar item or service provided by a similar provider in the same geographic region and indexed for inflation.

Here's a breakdown of what happens when a health plan receives a clean claim: