The No Surprises Act and Patient Estimation: What You Need To Know

On January 1, 2022, Congress passed the No Surprise Act to benefit both patients and physicians. Yet it mandates that medical practices comply with new standards. Is your facility effectively adhering to the new rules that are now in place?

Keep reading to find the key facts you need to understand about this new
law.

The No Surprises Act

This Act increases transparency and protects patients from surprise medical bills. One of the provisions ensures that patients receive emergency coverage without a PA. It doesn’t matter if the facility is in-network or if there are other plan terms.

Health plans can’t deny emergency coverage due to an after-the-fact care assessment. This included any claims of delays between the onset of symptoms and seeking care. The length of time the patient was symptomatic also can’t be used for a denial either.

Anyone with individual health or group plans qualifies for protection under this Act. This applies to most non-emergency care provided by in- or out-of-network facilities. It also includes out-of-network air ambulance services.

The Act also outlines the process for addressing provider and payment plan disputes. All patients have the right to receive a good faith estimate (GFE) of the charges upfront. Individuals including insured, self-pay, and uninsured can dispute unexpected bills from providers.

Patient Estimation

Providers must provide GFE to their patients before rendering services. Starting July 1, 2022, providers not following patient estimate rules will face penalties. The fines can reach up to $2,500 per instance of non-compliance.

There are seven requirements associated with providing patient estimates.

1. Defining “Self-Pay”

A “self-pay” patient includes those who are uninsured or choose not to use their insurance. All providers must ask the patient if they’re using insurance. If not, they must receive a self-pay estimate.

2. Mandated Written Notices

The physician practice must create a written notice of self-pay patients’ rights. This will include a GFE of the expected charges. Facilities are to post this notice where patients schedule services and on websites.

3. Verbal GFEs

Patient-included discussions or question/answer sessions about service costs meet GFE rules. You may wish to document this meeting.

4. Mandates for Written GFEs

All physician-provided written GFE must comply with federal regulations. All self-pay patients must receive this upon request or when scheduling services. The estimate is to include:

  • Patient’s name
  • Primary service in clear language
  • Itemized list of services
  • Diagnosis codes
  • Expected addition services not included in the estimate

5. Required Disclaimers

The estimate needs to include a disclaimer that the actual charges may differ. It must tell patients how to dispute charges that exceed the estimate by $400.

6. Timeframe for Delivering GFEs

The provider must give patients the GFE within one day of scheduling a procedure. This applies to procedures planned for at least three business days away. If the medical care won’t occur for at least ten days, the facility has three business days to deliver the GFE.

7. Handling GFE Changes

If the GFE changes, the physician’s office must notify the patient of the new GFE. This must take place at least one day before the medical intervention.

Patient Estimation Software

Exchange EDI offers a Patient Estimation tool that accurately generates GFEs. The system connects to your current Practice Management System. It will verify the patient’s current health plan eligibility for the intervention.

This tool lets you create on-demand estimates in seconds at check-in or -out. The patient payment estimator also bundles estimates when the visit involves multiple-CPT codes.

This real-time estimation tool allows you to collect more payments at the time of service. The system also accepts all forms of payment. Now you’ll spend less time trying to collect after the fact.

We also offer tools to manage your prior authorizations, our new outsourcing department that can handle your prior authorization tasks in your office today, eligibility and healthcare payments. Our patient portal and integration/API offerings are helpful for staff and patients. Patients can easily make payments via the portal or mobile pay.

Contact us today to learn more about our software solutions.

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