With the No Surprises Act taking effect in less than four months, it is critical that hospitals and providers leverage technology to ensure patients are informed about their expected care costs prior to receiving services. Despite industry improvements in the last several years, there remains a pressing need for more meaningful price transparency in healthcare. The No Surprises Act, in addition to recent revisions to existing Centers for Medicare and Medicaid Services (CMS) price transparency regulations1 and a policy push by President Biden2, aims to continue the trend toward more patient-centric healthcare that makes it easier for patients to navigate the inherent complexity.
On July 1, the Department of Health & Human Services released the first of three regulations that clarify key portions of the No Surprises Act. In the past, many patients have received unanticipated bills for emergency services or from out-of-network providers who provided services at the patient’s in-network hospital. The No Surprises Act prohibits healthcare facilities and providers who are outside of a patient’s insurance network from “balance billing” except under certain circumstances. For example, under the new requirements, an out-of-network anesthesiologist who participates in a surgery or an emergency department physician who cares for a patient may no longer balance bill when these activities occurred at a patient’s in-network hospital. Unless the patient receives notice and provides written consent3, providers may generally only collect cost-sharing amounts that would have been charged had the patient been in-network. This notice and consent process also requires out-of-network hospitals and providers to furnish “good faith estimates” to patients of their expected charges4.
While there are many outstanding questions5 on the No Surprises Act which will need clarification in future regulations, hospitals and providers should not wait to engage key stakeholders to ensure their technology and workflows can accommodate the dynamic nature of price transparency. In addition, while there are provisions for providing notice and consent for balance billing, the notice and consent approach cannot be used in many situations, such as for most emergency services, for defined “ancillary services” and when there are no in-network providers available6. Here are several overarching principles for proactively providing patients with the information they need to make decisions on their care as well as striving to avoid the situations that can lead to surprise medical bills.
- Leverage existing patient cost estimation tools to enhance transparency
To drive the patient experience, hospitals and providers should implement technology-enabled revenue cycle solutions to furnish individualized cost estimates at the time of scheduling. Many facilities already have online cost estimator tools in place to comply with certain portions of CMS’s existing Price Transparency requirements7. Providers should make sure their existing revenue cycle technology is able to flag patients who are out-of-network and provide accurate estimates. Doing so will help patients make better decisions about their care and reduce the likelihood that they will receive unexpected medical bills.
- Identify out-of-network situations prior to claim submission
One key provision of the No Surprises Act is that an out-of-network provider may not balance bill if there is no available in-network provider at a hospital8. While hospitals have struggled with identifying all providers who will be responsible for a patient’s care in advance (thereby increasing the likelihood that a patient receives an unexpected bill for out-of-network care), the new requirements provide an incentive for hospitals to actively coordinate care to ensure that patients are scheduled with in-network providers whenever possible. Hospitals should ensure that they properly identify all providers who are likely to be responsible for a patient’s care and establish a process to use the network checking capabilities of their revenue cycle solution to verify that providers are in-network. Hospitals and providers should also verify that their billing systems are not automatically assigning patient balances under circumstances that prohibit it under the No Surprises Act.
- Lean into the regulations to go above and beyond compliance
For many healthcare facilities and providers, new laws and regulations that impact key operational and financial processes can appear confusing and burdensome. However, hospitals and providers should lean into the intent of regulations to give patients more ownership over their healthcare decisions, and they should continue to push initiatives that further optimize revenue cycle processes that improve patient financial experiences. While an overarching goal of the No Surprises Act is to protect patients against high medical bills when they are unable to choose an in-network provider, the law does not protect patients in all scenarios. Yet another reason hospitals and providers should go above and beyond by delivering as much information as possible to patients about the expected costs of care.
The push for greater transparency in our healthcare system is here to stay. Moreover, staying ahead of price transparency is not only beneficial for meeting consumer and patient expectations but is also a critical factor in ensuring organizations are compliant with the rapidly changing regulatory landscape. Taking a proactive approach and leaning into meeting consumers where they are will distinguish organizations from their competitors and result in higher patient satisfaction and ultimately stronger financial performance.
Disclaimer: The information in this article is current as of July 26, 2021, and does not constitute medical or legal advice.
About Ogi C. Kwon, JD, MHA
Ogi C. Kwon, JD, MHA, R1 Manager, Advisory & Assurance – Regulatory, is a subject-matter expert for R1’s 200+ hospital customers on regulatory issues including Medicare & Medicaid requirements, Surprise Billing, the False Claims Act and Price Transparency. He is considered a thought leader on healthcare regulatory issues. In 2021 he was the featured speaker on Price Transparency at the National Association of Healthcare Revenue Integrity’s quarterly call and provided an exclusive interview with Chief Healthcare Executive.
1. FY 2022 Outpatient Prospective Payment System Proposed Rule, Section XIX, available at https://public-inspection.federalregister.gov/2021-15496.pdf.
2. See Executive Order on Promoting Competition in the American Economy, July 9, 2021, available at: https://www.whitehouse.gov/briefing-room/presidential-actions/2021/07/09/executive-order-on-promoting-competition-in-the-american-economy/.
3. The notice and consent process does not apply to a variety of different scenarios, including for emergency services as well as certain “ancillary services” (e.g., anesthesia and radiology). See 86 FR 36872 at 36982.
4. 86 FR 36872 at 36983.
5. Outstanding questions include how the No Surprises Act will change current practices in states with existing balance billing protections as well as what constitutes “good faith estimates” for the purposes of notice and consent.
6. 86 FR 36872 at 36982.
7. 45 CFR § 180.60(a)(2) (“Requirements for displaying shoppable services in a consumer-friendly manner”).
8. 86 FR 36872 at 36982.