The No Surprises Act: Preparing Your Practice for the Coming Challenges and Opportunities

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Co-written By Juli Smith, Director, ZOLL Data Systems

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Mark R. Jones, President and CEO, EMRJ Consulting Apr 27, 2021

Co-written By Juli Smith, Director, ZOLL Data Systems

The bipartisan No Surprises Act (“the Act”) was enacted on December 27, 2020. The Act provides comprehensive patient protection against surprise medical bills that occur when a patient receives a bill for the difference between an out-of-network provider’s charge and the amount paid by the patient’s insurance company. Specifically, the Act protects patients from surprise bills for: “1) emergency services delivered by out-of network providers, including emergency air transport, or by out-of-network facilities; and 2) nonemergency services provided by out-of-network providers in network facilities and for which patients do not consent.”¹.

No Surprise Act

Key Provisions of the No Surprises Act

For those responsible for healthcare billing, some of the most noteworthy provisions of the Act are:

Effective January 1, 2022, prohibits balance billing except under very defined circumstances
Applies to Employee Retirement Income Security Act (ERISA) plans and to state-regulated plans in states where a balance billing law doesn’t exist already
Patient deductibles for out-of-network emergency care are the same as for in-network care, and deductibles must be printed on insurance cards
Requires a qualifying payment directly to the provider or response with a full denial within 30 calendar days of claim receipt
Creates an accessible Income-driven Repayment (IDR) process to address out-of-network payment disputes

With many of the more important provisions of the Act not completely defined, how can a medical practice prepare for the provisions of the law?

Understand applicability of the law in the state(s) where the practice is located.
Have a mechanism in place to identify current out-of-network payment trends and compare them to payments received after January 1, 2022.
Be prepared to take underpaid claims through the IDR process.

Understanding Applicability of the Law

The No Surprises Act applies to any state where a law prohibiting balance billing does not already exist. In states where a law does exist, state law will supersede the Act.

Benchmarking Current Payment Trends to Compare to Future Payments

Reporting from a practice’s billing system should provide average reimbursement by CPT code and by payer from past time periods in order to identify the average qualifying payment made for the same services in 2022.

Taking Underpaid Claims Through the IDR Process

Likely the most important piece of the Act for providers is the creation of a robust and easily accessible IDR process to dispute the payment amount of claims. High level provisions include:

No minimum dollar threshold to access IDR, and up to 30 days of claims can be batched according to defined criteria.
Numerous factors are considered during the IDR process, but no factor takes primacy.
Other factors, especially surrounding various payment benchmarks, are NOT to be considered.
Well-defined timeline for the IDR process, including negotiation, final decision, and cooling off periods.

Though much of the Act has yet to be defined, it is never too early to take proactive steps to prepare for successful navigation of the new payer landscape on the horizon in 2022. To learn more about the ramifications of the Act, read on here.