No Surprises Act a Big Surprise to Many Health Care Providers

Posted on Nov 29, 2021 by

Are you a licensed health care provider who sees any uninsured or self-pay patients? Do you operate a health care facility, like an ambulatory surgical center or federally-qualified health center? Are you a health care provider who provides care at a hospital or other facility that is in-network with more insurance plans than you are? If any of these apply to you, then the No Surprises Act requires you to take action before January 1, 2022.

Background.

Signed into law in December of 2020 and expanded in scope on September 30, 2021, the No Surprises Act is intended to protect consumers from surprise health care bills. However, it creates a lot of work for health care providers already dealing with a global pandemic and vaccination mandates. The No Surprises Act was originally largely limited to the goal of preventing balance billing from out-of-network providers giving care at in-network facilities. (Picture a patient going in for surgery at a hospital covered by their insurance being surprised to learn afterward that their anesthesiologist was out of network, and being even more surprised to have to pay the balance of the anesthesiologist’s bill.) With those situations in mind, the No Surprises Act requires that patients be notified ahead of time if one of their providers at a facility covered by their insurance is out-of-network and also be provided with a good faith estimate of what their visit is likely to cost.

The No Surprises Act also requires that licensed health care providers of any kind (physicians, dentists, chiropractors, physical therapists, etc.) provide uninsured and self-pay patients with a good faith estimate of any upcoming appointment in advance.

The No Surprises Act goes into effect on January 1, 2022. Here’s what you need to do to get ready.

Facilities.

If you operate a facility such as a hospital, ASC, rural health center, FQHC, laboratory, or imaging center licensed by state or local law, you must develop a Disclosure Notice Regarding Patient Protections Against Balance Billing, such as this form provided by the federal government. This notice must be prominently displayed on a sign in the facility, such as where individuals schedule care, check-in for appointments, or pay bills. The notice must also be posted on your website, with a link appearing on your homepage. And, the notice must be provided to any insured patient, either in person or through mail or email (as selected by the patient).

If third party providers (such as anesthesiologists or radiologists unaffiliated with your facility) provide services at your facility, and if there are ever circumstances in which one of those providers may be out of network even though the facility is in-network for an insurance plan or other payer, you’ll have to take additional steps. You must develop a Notice and Consent document, notifying patients of their rights under the No Surprises Act and providing them with a good faith estimate of what their care is likely to cost. (A sample Notice and Consent document from the OMB can be found here.) Other than in emergency situations, you must give this Notice and Consent document to any patient who is out of network with a provider who will provide services to that patient at your facility, or ensure that any applicable out-of-network provider is giving patients this notice and consent form directly.

Providers.

If you are a licensed health care provider, and you bill any uninsured or self-pay patients, you must begin informing all uninsured and self-pay patients of their right to receive a good faith estimate of the cost of their visit, at the time of scheduling or upon their request. (A sample notice can be found here.) You must develop a form for good faith estimates (also found here), and you must post the notice of availability of good faith estimates on your website and in the office where scheduling or questions about the cost of health care occur. You must provide uninsured and self-pay patients with a good faith estimate of the cost of their visit within 1-3 days of the date of scheduling (depending on how far out the scheduled appointment is).

If you are a licensed health care provider who provides services at a hospital, ASC, rural health center, FQHC, laboratory, or imaging center licensed by state or local law, you should consider entering into an agreement with the facility in which the facility will agree to provide required disclosure notices to your patients receiving services at the facility. If the facility will not enter into such an agreement, you are responsible for ensuring that all your insured patients who receive your services at a facility are given a disclosure notice on balance billing.

And, if you might ever be out of network for an insurance plan in which the facility participates, you should coordinate with the facility and ensure it will be providing patients with the required Notice and Consent document. If the facility will not be giving this form to your out-of-network patients, then you must develop the form and ensure it is given to the patients yourself.

Here to Help

At McCarty Law LLP, we’re here to help! If you are a provider or facility and need assistance wading through these requirements and developing forms and processes, please contact Lora L. Zimmer at [email protected] or 920-257-2214.

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Lora L. Zimmer

Health Law and Title IX Attorney at McCarty Law LLP
Lora focuses her practice in corporate and business transactions, with a particular focus on the business and regulatory needs of health care clients. In addition, Lora is a trained Title IX investigator, providing prompt, thorough investigations and objective reporting in response to alleged violations of schools’ sexual misconduct policies.