Preparing for some surprises in the No Surprises Act

John Talaga
John Talaga
is the Executive Vice President and General Manager in Healthcare.

The No Surprises Act, which went into effect January 1, is an important piece of legislation that provides important financial protections for patients as they continue to take on a larger share of their healthcare costs. Specifically, it protects patients from surprise bills for care outside of their insurance network. Healthcare providers are now required to provide “good-faith estimates” in advance of treatment for all costs including both primary and ancillary services required. Federal projections suggest it will prevent approximately 10 million surprise bills a year.

The rules under the Act also require health care providers and facilities to provide patients with easy-to-understand notices explaining the applicable billing protections and who to contact if patients have concerns that a provider or facility has violated the protections. In addition, it establishes an independent dispute resolution process for payment disputes between plans and providers.

The net result: Patients will be more informed about their obligations, protected from surprise charges, and will no longer have to get involved with disputes between providers and insurers. Those are all important and timely advancements for the industry.

In speaking with healthcare providers, they have come across a few surprises they are having to account for to smooth the transition for their staff and their patients. These might be helpful as you think through the impact of the Act on your own operations.

Count on more paper in the short term

One of the core tenets of the No Surprises Act is the requirement to notify patients of their rights (disclosure notices), and projected costs. Patients have the option to select how they want to receive this information — in-person, by mail, via email, or online, and in what language. Providers must issue the disclosure notice and good faith estimate at specific times related to when procedures are scheduled and when the provider requests payment. In many cases, the patient may not have had the option of selecting their preferred method of delivery in advance so, a lot of these notices may have to be delivered via paper, at the point of consultation or service.

Capturing patient information

The No Surprises Act requires providers to capture a patient’s information every time they prepare a good faith estimate. For a patient using the system once or twice a year, that’s no big deal. But for chronic patients, or those who use the healthcare system more frequently, that can come across as seemingly an unnecessary redundant request, and an annoyance for some patients. It may be helpful to alert staff to this inconvenience and counsel them on working with patients that voice their frustration with it.

Notifying invisible patients

There are whole segments of patients that providers don’t speak or interact with, for example some patients in the ER or those having lab work done. There is limited opportunity to ask them about their preferences for receiving their disclosures. Providers have to solve for that. Sending the disclosure with the statement or bill may not necessarily be the way the patient wants it, but at least the patient receives it.

Price Transparency vs. No Surprises Act

There is some redundancy between recent “Price Transparency” requirements and the No Surprises Act. Each has distinct requirements involving a lot of the same information. Unfortunately, you won’t be able to substitute one for the other.

Federal vs. state dispute resolution

The Independent Dispute Resolution (IDR) process involves arbitration for qualified payments. But there are different rules for federal vs. individual states. This can create some complexity for providers, especially those with multiple facilities in different states, to sort through as they try to claim compensation for services delivered.

Estimation tool updates

The No Surprises Act requires providers to update their estimation tools. This likely involves multiple vendors and all the information has to be stored in the provider’s EMR systems. That may require scanning information from estimation tools into their EMR.

Patients who are more informed about their rights and their financial obligations benefit everyone in the healthcare ecosystem. And the No Surprises Act supports those goals. To smooth the transition for themselves and their patients, providers are sorting through and deploying some short-term adjustments.