How No Surprises Act Affects Healthcare Insurance Eligibility
tevixMD is releasing a new service module in the future “tEstimator” for the No Surprises Act. This new module will use our exclusive technology under tevixMD’s solution to provide support and protect providers for the No Surprises Act, providing better results and ease of use. We’ll tell you how it works, what it does and what you need.
As we expect to release, what are you currently doing about the No Surprises Act? If you have questions or concerns regarding the new law, you can request a discussion with one of our Subject Matter Experts who will provide helpful information regarding what is needed to be compliant with the No Surprises Act.
What is the Goal of the No Surprises Act?
Congress passed H.R. 3630 also known as the No Surprises Act. “To amend title XXVII of the Public Health Service Act to protect health care consumers from surprise billing practices, and for other purposes.” (https://www.congress.gov/bill/116th-congress/house-bill/3630/text)
The goal of this law is to provide patients with an understanding of their healthcare costs and prevent unexpected (or surprise) medical bills. “Effective January 1, 2022, the No Surprises Act (NSA) protects patients from surprise billing if you have a group health plan or group or individual health insurance coverage, and bans:
Surprise bills for emergency services from an out-of-network provider or facility and without prior authorization
Out-of-network cost-sharing, like out-of-network coinsurance or copayments, for all emergency and some non-emergency services
Out-of-network charges and balance bills for supplemental care, like radiology or anesthesiology, by out-of-network providers that work at an in-network facility
The No Surprises Act also requires some health care facilities and providers to disclose Federal and State patient protections against balance billing and sets forth complaint processes with respect to violations of the protections against balance billing and out-of-network cost sharing.”
What Do You Need for the No Surprises Act?
Billing transparency between the patient and provider is key to preventing billing issues and disputes. If a provider does not disclose accurate amounts for medical billing, this can cause higher than expected costs for the patient. It is important for the provider to be aware of the requirements for No Surprises Act to be protected from lawsuits.
Providers will need to provide 3 separate machine-readable files (Excel, JSON, CSV) for the following:
In-Network: Negotiated Drug Rates & Prices
In-Network: Negotiated Rates
Out-of-Network: Average Charges and Payment by Provider
2 key pieces of data to provide billing transparency:
Who is the patient?
What is their insurance?
If your patient data is incorrect, you will not meet the requirements for the No Surprises Act. Providers will be required to provide a Good Faith Estimate. To provide a good faith estimate, it is essential to verify the patients’ health insurance eligibility status. It is vital that your current vendor is accurately identifying your patients and their insurance eligibility status to comply.
What is a good faith estimate? This estimate requires that providers provide uninsured, self-pay and out-of-network (OON) patients of anticipated charges for a scheduled procedure. This requires provides to ensure they are properly identifying the patients’ health insurance status to determine the Good Faith Estimate.
In addition, providers are required to post a notice on their website and provide patients with a one-page notice regarding the balance billing protections, state requirements and contact information.
Ensure you have the right system in place to automate healthcare insurance eligibility and create billing transparency for the patient. With intelligent verification, you will capture the most accurate patient data and healthcare insurance eligibility information needed to be compliant for the No Surprises Act.
What are the Top 3 Challenges Providers Face with No Surprises Act?
According to Norton Rose Fullbright (https://www.nortonrosefulbright.com/en-us/knowledge/publications/86228dc0/operational-challenges-of-the-no-surprises-act-continue-to-surprise-providers), the top 3 requirements from No Surprises Act to be raising the most concerns are good faith estimates, notice and consent, litigation and the Independent Dispute Resolution (IDR) process.
Good faith estimates
Notice and consent
Litigation and the Independent Dispute Resolution (IDR) Process
It is now more important than ever to accurately verify the patient and their insurance information. Otherwise, you could be faced with the Litigation and the Independent Dispute Resolution (IDR) Process. The IDR process can occur between a provider and a health plan when there is a payment dispute. Providers need to watch out for these disputes as the initiations for the IDR process can be submitted in just a few minutes using a short questionnaire. For more information regarding the IDR process, visit https://nsa-idr.cms.gov/paymentdisputes/s/
What To Do Next?
Now that the patient is protected, are you? The first step to tackling the No Surprises Act requirements is to ask yourself if your current solution is accurately identifying your patients and their insurance eligibility status. If your current data is not reliable, you may experience difficulties complying with the No Surprises Act. If you have any questions or concerns regarding the new law, contact one of our Subject Matter Experts who will help you prepare. We make it easy. We’re here to help.
Disclaimer: tevixMD is not providing legal advice, we are only providing information on how our solution can help you be compliant with the No Surprises Act.