No Surprises Act

Key points that could impact your revenue cycle

Please refer to the CMS Fact Sheets for additional information.

Updated as of 01/07/2022

On July 1, 2021, CMS began releasing the Interim Final Rules aimed at protecting consumers from surprise medical bills. This was the first of several rules that will guide the industry in implementing the No Surprises Act (NSA).

The No Surprises Act aims to protect patients from surprise medical bills. A surprise medical bill happens when a patients seeks care from a provider or facility with the expectation that the services and items will be covered by their insurance plan and receive an unexpected bill, a surprise bill.

The No Surprises Act part II extends protections to uninsured and self-pay patients.

The NSA applies to employer-based coverage, (including a federal, state, or local government), plans purchased through the federal marketplace, state-based marketplaces, plans purchased through an individual market health insurance issuer and Federal Employee Health Benefits (FEHB) plans.

As regulations continue to evolve, we will continue to update this information as it becomes available.

The No Surprises Act – Effective January 1^st (with some delayed enforcements)

Key Points

No Surprises Act: Part 1

The NSA protects patients seeking emergency services at an in and out-of-network facilities.

Patients are only responsible for deductible, co-insurance, co-pays and in network charges. Patients cannot be billed as OON for emergency services.

Health plan must process emergency claims as in-network, without requiring prior authorizations.

All non-emergency services furnished by out of network providers at in-network facilities require a good faith estimate (GFE) signed by the patient.

The good faith estimate will indicate that the provider(s) performing services are out of network and will detail the patient’s expected out of pocket expenses *

Surprise billing for air ambulance services is prohibited

No Surprises Act: Part 2

Dispute resolution for out-of-network charges is instated

Payment disputes for providers, facilities, and air ambulance services are covered.

Providers and facilities are required to inquire about the individual’s health insurance status

If the individual is enrolled in one of the covered health plans, the provider must ask if the individual is seeking to have a claim submitted to their insurer. If not, the individual is considered self-pay.

Providers or facilities must provide a good faith estimate of expected charges for items and services to an uninsured or self-pay patient.

Estimates must include expected charges for the items or services that are reasonably expected to be provided with the primary item or service, including items or services provided by other providers and facilities **
It must be noted that the HHS will exercise enforcement discretion where a good faith estimate is provided to an uninsured or self-pay patient does not include expected charges from other providers and facilities
Health and Human Services will exercise discretion regarding charges from co-providers and co-facilities will last from January 1 through December 31, 2022 **

* NSA Part I – 2799B-2(d)
** NSA Part II – 149.610(g)(2)

TPS INSIGHTS

We know you’re busier than ever and your staff is stretched thin, so our team of experts is prepared to deliver whatever support you need. The following information is available to help our clients manage their practices.

New No Surprise Act Tackles Unexpected Medical Bills

72 million Americans have some sort of trouble paying medical debt. Much of this can be attributed to unexpected bills that pop up after unforeseen emergency visits and treatment from out-of-network providers. Thanks to new regulation, surprise medical bills may soon be a thing of the past.

Equip your practice with the right tools from TPS

Patient Eligibility

It’s critical to know the health plan coverage for every patient who will receive qualifying services. Review patient eligibility processes to ensure that they are optimized, allowing staff to efficiently determine coverage and expected out-of-pocket costs.

Patient Eligibility and
Insurance Eligibility Discovery

Patient Responsibility Estimation

In the age of healthcare consumerism, most patients are aiming to understand their costs associated with healthcare. Utilize the TPS estimation tool as a part of the scheduling process for qualifying services to assist in providing clear and accurate estimates.

Patient Responsibility Estimation

Denials and Contract Management

TPS Denials and Contract Management tools can help your organization track out-of-network claims so that reimbursement can be monitored, as well as tools to assist your office in the negotiation and dispute resolution process, if needed.

Denials and Contract Management

paperResolve™

Considering that out-of-network services are likely to have a high claim value, it’s important not to lose track of them. Out of network payers may send payment on paper – which can now be transformed into electronic remittance advice. Not only does this save effort and time, but it enables the TPS Denials and Contract Suite to identify out-of-network claims and track them automatically.

paperResolve™