No Surprises Act: Ensure compliance at your healthcare organization

Congress passed the No Surprises Act in December 2020, and your healthcare organization has until Jan. 1, 2022, to prepare. The law protects patients from receiving surprise medical bills as a result of gaps in coverage for emergency services and certain services provided by out-of-network clinicians at in-network facilities, including by air ambulances.

Patients will be liable only for their in-network cost-sharing amount, while giving providers and insurers an opportunity to negotiate reimbursement. Providers and insurers will have access to an independent dispute resolution process in the event disputes arise around reimbursement; however, the legislation hasn’t set a benchmark reimbursement amount yet. The law also requires both providers and health plans to assist patients in accessing healthcare cost information.

Patients will be liable only for their in-network cost-sharing amount, while giving providers and insurers an opportunity to negotiate reimbursement.

The No Surprises Act also tries to increase transparency for all patients to better understand their cost-sharing liability ahead of time. For instance, consumers can receive an Advanced Explanation of Benefits before a healthcare service is delivered. This document must provide a good-faith estimate of costs and cost sharing; it must identify whether the provider(s) furnishing the items or services is in-network and, if not, how to find in-network providers. Insurers also will have to offer price comparison information by phone, develop a web price comparison tool, and maintain up-to-date provider directories.

How to prepare for the No Surprises Act

To make sure your organization is ready to comply with the Act, take the following steps:

• Analyze billing data: Review the data to identify the extent of surprise billing exposure.
• Review existing laws: Consider which surprise billing laws already exist in the states in which you operate.
• Identify those responsible for compliance: Make sure you know exactly who should be monitoring compliance to avoid letting it fall to the wayside.
• Update processes and allocate resources: Review your processes currently in place to ensure you can meet compliance laws and reallocate resources as necessary to adequately support the processes.
• Review patient billing policies: Take a look at your patient billing policies, make updates, and be sure to clearly communicate any changes.
• Train your staff: Promptly update all relevant staff on any policy or process changes related to patient billing practices. Include any revenue cycle, managed care, IT, finance, legal, and compliance staff in discussions.

Once requirements and implementation plans are determined, healthcare organizations should develop communications for patients about consumer rights and price transparency.

Internal audit and compliance should consider testing areas for compliance, once in effect, or should consider including auditing around this area in audit plans.

Mitigate risk with additional support

Preparing for these changes will take time and effort, so start sooner rather than later. And remember, you don’t have to do it alone. We can help you prepare — give us a call if you need guidance.