No Surprise Act AKA Good Faith Estimates

The Centers for Medicare & Medicaid Services (“CMS”) effective January 1, 2022 has ramped up the new No Surprise Act (“NSA”) or often called the “Good Faith Law”. This law shall apply to group health plans, health insurers, health care providers and health care facilities (“Providers”). The NSA requires health care providers to be proactive and reactive as it relates to providing patients who are self-pay or shall receive out-of-network bills from their health insurance a pre-bill outlining the services they are intending to receive and could potentially receive.

Self-Pay

Self-Pay patients apply to a wide range of medical providers; therefore, the importance of this law is crucial for providers accepting cash patients. The provider will be required to transmit to patients itemized disclosures of the services offered at the facility, these disclosures are called “Good Faith Estimates”. A Good Faith Estimate will include various detailed terms that a patient must have upon request, or a provider will be required to inform a patient that said estimate is available to them when inquiring about services. The disclosure will be required at the front desk and on the providers website.

Out-of-Network

If a provider treats patients who have insurance coverage and is not in network with said insurance plan, the provider is subject to and will have to abide by the NSA.

The driving complaint by patients that lead to the institution of the NSA was surprise medical bills, which are essentially caused by balance billing. Balance billing occurs when a provider bills an amount or difference not covered by an insurance plan. Under the NSA, providers will have to implement the proper disclosure requirement of this practice, which must be presented to patients prior to the treatment. Providers will be required to obtain notice and consent forms signed by patients authorizing any additional billing not covered by the out-of-network coverage prior to providing said treatment.

Does Not Apply To

The NSA will not apply to vision or dental insurance plans which are solitary plans. However, if the vision and dental is an added benefit to a health plan it will be covered. The NSA will not apply to balance billing practices for those in the ground ambulance business. Providers who service Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care, or TRICARE shall not apply to NSA.

Penalties for Non-Compliance

A patient shall be allowed to dispute any bill charge in excess of $400 personally or through an independent third party, a “dispute resolution entity”, which shall determine the amount owed by the patient. An email shall be sent to the provider stating that a dispute has arisen, and the provider will be required to upload certain documentation surrounding the dispute. During a dispute resolution period, providers will not be allowed to move the bill into collection or threaten collection, if collection is already ongoing it shall be paused, late fees on the unpaid bill shall not be collectable, and any threats of retaliation against the disputing patient shall not be permitted. However, providers shall have the option to settle the claim with a patient directly abiding by the above, upon executing a settlement form. Failure to adhere to the NSA shall result in penalties up to $10,000 per violation.

No Surprise Billing Requirements to be Implemented Jan 1, 2022

On January 1, 2022, a new federal law, “Requirements Related to Surprise Billing, Part I” (“The Rule”),  goes into effect for health care providers and facilities and for providers of air ambulance services.  The Rule will restrict excessive out-of-pocket costs to consumers which resulting from surprise billing and balance billing.

Group health plans and health insurers contract with a network of provider and health care facilities, these providers are considered as in-network providers.  They agree to accept a specific payment for their services.  Providers and facilities that are not contracted with a health plan or insurer are known as out-of-network providers (OON). They usually charge higher amounts than in-network providers.  When OON providers do not receive full payment for their charge from the insurance payor, they charged the patient for the difference between the charge and the amount paid, a practice known as balance billing.Continue reading

HMO Patient Emergency Care Reimbursement

Compliance With Laws & Regulations

By: Bradley M. Seldin, Co-counsel Guest Contributor

Prohibitions against balance billing Health Maintenance Organization (HMO) patients have been around for more than a decade, but many non-contracted providers to HMO patients still don’t fully understand their rights to payment when it comes to collecting monies from patients and HMO’s.

HMO’s often have predetermined rates they pay to non-contracted healthcare providers; sometimes they are artificially low, do not reflect what is written in the member’s contract, or do not abide by what is required by applicable law.  As a result, these providers may end up being underpaid if they don’t have a written contract with the payor and they do not understand the payment methodology being applied to them.  This is of particular significance to emergency care providers. ER doctors and hospitals must, by law, provide emergency care without regard to whether the patient has an ability to pay for the treatment received.

Following their provision of emergency care, medical providers often question the payment obligations under the patient’s Health Maintenance Organization contract. If the emergency medical provider has a direct written contract, the reimbursement is governed by that participating provider contract’s reimbursement terms.

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