The No Surprises act requires providers to supply a good faith estimate for cost of care

The No Surprises act requires providers to supply a good faith estimate for cost of care

In December 2020, Congress passed the No Surprises Act (NSA), which is intended to protect patients from unexpected out-of-network (OON) “surprise” medical bills. Congress delayed the bill’s effective date until Jan.1, 2022 to allow federal agencies time to implement the regulations.

The law is large and complex. Some provisions are limited to hospital and emergency settings, others apply more broadly across the health care system.

For 2022, allergy practices are responsible for complying with the good faith estimate (GFE) for care they reasonably expect to provide to uninsured and self-pay patients. The Centers for Medicare and Medicaid Services (CMS) published a GFE template form for practices to use.

The NSA’s patient protections apply to OON care furnished at an in-network facility, which the NSA defines as a hospital, advanced surgical care center (ASC), critical access hospital (CAH), freestanding emergency department (ED) or an urgent care center licensed to provide emergency services. Allergists who provide OON services at these health care settings could experience scenarios subject to these protections.

The above protections do not apply to the physician office setting and therefore would not apply to many allergy practices.

The NSA includes two primary components. The first is patient protections from “surprise” OON care furnished at an in-network facility. For background, surprise medical bills were historically regulated by state laws. However, not every state had a surprise billing law and those that did lacked jurisdiction over federally regulated health plans such as ACA plans and ERISA plans. Congress passed the NSA to protect patients where state law either does not exist or lacks jurisdiction.

Of note, the Department of Health and Human Services (HHS) has the authority to expand these protections to other health care settings.

The NSA specifically protects commercially insured patients from large medical bills for OON care provided at an in-network facility. This includes all OON emergency care and care provided by OON providers at a facility that is in-network to the patient. It also creates an arbitration process, called independent dispute resolution (IDR), for resolving reimbursement disputes between out-of-network providers and the patient’s health insurance plan.

In a circumstance where NSA applies, the patient’s in-network cost-sharing would apply to OON care. Cost-sharing on OON care would count towards the annual deductible and out-of-pocket premium. Providers are prohibited from balance billing the patient for more than their cost-sharing. Furthermore, cost-sharing is not based on the providers’ OON charge. Instead, it is based on the qualifying payment amount (QPA), which is defined in the regulation as the health plan’s median in-network rate as of January 31, 2019 indexed to inflation.

The second component is a requirement to provide an advanced “good faith estimate” (GFE) of the anticipated cost for care to uninsured and self-pay patients either upon request or when scheduling care. This provision applies essentially to all health care providers. Self-pay patients have insurance but choose not to have the bill submitted to their health insurance and pay out-of-pocket instead.

Many practices already provide cost estimates to patients upon request. This policy establishes requirements for how quickly the estimate must be furnished and standardizes the information that must be included. Details on the timeline for providing the GFE include:

  • If an uninsured or self-pay patient requests a GFE, the provider has 3 business days to issue the GFE.
  • If an uninsured or self-pay patient schedules care at least 10 business days in advance, the provider has 3 business days to issue the GFE.
  • If an uninsured or self-pay patient schedules care at least 3 business days in advance, the provider has 1 business day to issue the GFE.
  • If an uninsured or self-pay patient schedules care less than 3 business days out, then the provider is not required to issue an uninsured or self-pay GFE.

The GFE must include services that the provider “reasonably expects” to provide – the specific costs estimates – with service codes. The GFE should also “include the period of time during which any facility equipment and devices, telemedicine services, imaging services, laboratory services, and preoperative and postoperative services that would not be scheduled separately by the individual, are furnished. It is the intent of this definition of ”period of care” to clarify that the good faith estimate should include all of the items or services that are typically scheduled as part of a primary item or service for which an individual does not need to engage in additional scheduling.”

It also aims to provide patients with the ability to compare their health plan’s price with the self-pay price while providing greater price transparency for uninsured patients.

CMS is delaying enforcement of a provision of the GFE that also requires the estimate to include connected care from other providers and facilities, because CMS recognizes how challenging it will be to implement this and other operationally complex requirements. CMS also is delaying enforcement of the GFE for self-pay patients who want the bill submitted to their health plan. Eventually, CMS expects the GFE to include connected care and allergists will need to coordinate with other practices as either the convening provider or the co-provider.

CMS has also delayed enforcement of the requirement for health plans to provide patients with an advanced explanation of benefits (AEOB). The AEOB must include the GFE, meaning providers will need to coordinate with the patient’s health plan to provide the GFE information necessary for the health plan to comply with the AEOB requirement.

The NSA also provides patients with some recourse if their bill “substantially” exceeds their GFE. Patients can challenge a bill that exceeds the GFE by $400 or more using a newly established arbitration process modeled off the NSA’s IDR process for “surprise” bills.

The Advocacy Council is developing a comprehensive overview of the GFE that will be available soon. CMS has a website dedicated to the NSA with additional resources.