Understanding of No Surprises Act & Good Faith Estimates for 2023 Billing

Basics of No Surprises Act

The No Surprises Act went into effect on January 1, 2022. This Act is aimed at reducing ‘surprise bills’ to patients in the context of services provided at hospitals and ambulatory surgical centers and includes requirements for hospitals and ambulatory surgical centers, as well as physicians providing services at such facilities. When a patient gets emergency care or gets treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, they are protected from surprise billing or balance billing. Knowledge of the No Surprises Act & Good Faith Estimates is crucial for all healthcare providers irrespective of their medical specialties.

Generally, a ‘surprise bill’ is one that the patient receives for services from a provider who the patient was not aware was out-of-network with their insurer. Surprise bills often occur with emergency services or with non-emergency services received from non-participating providers at in-network facilities, such as out-of-network anesthesiologists at an in-network hospital. The No Surprises Act prohibits certain balance billing by out-of-network providers and mandates a set of disclosures with respect to healthcare services provided at hospitals and ambulatory surgical centers

New Surprise Billing Requirements and Prohibitions 

  • No balance billing for out-of-network emergency services 
  • No balance billing for non-emergency services by out-of-network providers during patient visits to certain in-network healthcare facilities, unless notice and consent requirements are met for certain items and services. 
  • Providers and healthcare facilities must publicly disclose patient protections against balance billing 
  • No balance billing for covered air ambulance services by out-of-network air ambulance providers 
  • In instances where balance billing is prohibited, cost sharing for insured patients is limited to in-network levels or amounts 
  • Providers must give a good faith estimate of expected charges to uninsured and self-pay patients at least 3 business days before scheduled service, or upon request 
  • Plans and issuers and providers and facilities must ensure continuity of care when a provider’s network status changes in certain circumstances 
  • Plans and issuers and providers and facilities must implement certain measures to improve the accuracy of provider directory information

The Act permits certain out-of-network physicians to bill a patient and the patient’s insurance plan at the full out-of-network rate for services provided at an in-network facility, but only if the physician provides a separate disclosure to the patient and obtains the patient’s written consent at least 72-hours prior to their appointment. Otherwise, balance billing for that service is prohibited.

Good Faith Estimates

The No Surprises Act also addresses uninsured Individuals. This Act requires providers to give a good faith estimate of the expected charges for non-emergency services to any uninsured (or self-pay) patient within certain timeframes following the scheduling of that service. The estimate must contain certain information as detailed by the Act. The Act also requires providers to inform all uninsured (or self-pay) patients of the availability of a good faith estimate of expected charges in connection with scheduling a service or upon request. The notice must be prominently displayed on-site at the provider where scheduling or questions about the cost of items or services occur and published on an easily searchable part of the provider’s website.

2023 Surprise Billing Final Rule

U.S. Department of Health and Human Services (HHS) recently released final rules for implementing components of the No Surprises Act. These rules expand upon previous interim final rules regarding the qualified payment amount (QPA) and the federal independent dispute resolution (IDR) process. The final rules require additional documentation regarding the QPA. The QPA is the insurer’s median in-network rate for the same or similar service, at the same or similar facility, by a provider of the same or similar specialty, and in the same or similar geographic area. The rules state that the QPA will no longer be the presumptive factor in payment determinations. Instead, certified IDR entities must first consider the QPA, and then ‘must consider all additional information submitted by a party to determine which offer best reflects the appropriate out-of-network rate.’ According to the final rules, certified IDR entities should choose ‘the offer that best represents the value of the item or service under dispute after considering the QPA and all permissible information submitted by the parties.’

Understanding of No Surprises Act & Good Faith Estimates

Proper understanding of the No Surprises Act & Good Faith Estimates will ensure you are not balance billing even in case of emergency billing. MedicalBillersandCoders (MBC) which is a leading medical billing company can assist you in accurately billing under the No Surprises Act. Our eligibility and benefits services can assist you in sharing good faith estimates with patients. To know more about our billing and coding services, contact us at 888-357-3226 / info@medicalbillersandcoders.com