The No Surprises Act comes into effect on January 1, 2022, with fundamental principles in place and several others in a row to be implemented gradually. Noted as one of the most vital laws in recent times concerning billing in healthcare, the No Surprises Act has been the subject of thorough studies for a long time for every stakeholder in the American medical industry. Some health systems have already implemented every facet of the law. But still, more than 50% of hospitals were yet to comply with the regulations as per research in early 2021.

The NSA affects the various workflows of the different organizations and demands change from the teams from billing in healthcare. With severe staff shortages throughout the healthcare business, management teams are finding it difficult to cope with the various issues that come with it. They need competent professional staff who know the way around and who can implement the evolving rules in an existing traditional setup. Optimizing the billing workflow in healthcare is crucial if you do not want to lose out money on non-compliance fees.

Components of the Act

  • The main impact of the No Surprises Act falls more on out-of-network providers than on in-network providers due to the constraints in existing billing rates.
  • The protection from surprise bills comes in the case of most emergency services. They include hospital emergency rooms, standalone emergency clinics, and urgent care centers. Emergency services also include air ambulance transportation.
  • With the NSA in effect, the out-of-network providers cannot bill the patients any more than the in-network sharing amount.
  • Balance billing the patient is also wholly prohibited on all terms. This is a positive step towards providing more control of the patient’s hands-on healthcare costs.
  • The out-of-network providers cannot bill the patients for any non-emergency services if they undergo any treatment in an in-network hospital.
  • Any violation of the No Surprises Act on the part of the health systems will lead to a hefty fine of $10,000. In this case, the consumer, that is, the patient will be able to appeal for any non-compliance-related issues to the enforcement authorities.
  •  The median rate for the treatment during the ‘surprise visit’ should be negotiated among the health plan panels and the providers. The rates will most likely be around the same rate paid to in-network providers for the same treatment.
  • There is an option of independent dispute resolution if the providers and the health plan authorities cannot decide on their own.
  • The patients can also waive off their surprise billing rights if they want to on their own. This can be processed only with written consent from the patients. The providers or the health systems cannot force the patients for the same, and the move must be voluntary.

Will the providers lose out on money?

  • Will the providers lose out on money that they have been historically making for the last few years with the No Surprises Act in effect? It is the most pressing question making rounds since the law has been enforced.
  • While there is no one correct answer to this question, the providers should know their options well before adjusting to a new billing system in healthcare.
  • Experts believe that the out-of-network providers will lose out on particular money since they will have to adjust with the in-network median rates as per the law.
  • To make up for the loss, out-of-network providers expect specific incremental rates of the current in-network costs. However, the increase is expected to be slowly implemented.
  • The providers need to wait until the payer networks, providers, and the overall healthcare market agree and stabilize the prices.
  • It is also vital to understand the rate spread in the market before the providers agree to the standard rate during the emergency treatment options.
  • The balance billing, though mostly prohibited, can be used in the case of specific non-emergency care services like the outpatient mental health providers or the services offered in a physician’s office.
  • The providers need to understand under which conditions the different components of the No Surprises Act will come into play. Therefore they must be under the professional guidance of expert individuals involved in billing in healthcare.

Important Takeaways

  • With the new law in effect, billing in healthcare is undergoing several changes in the way that it functions on a daily basis. To understand the different effects on the revenue flow in the long term, the providers need a data-driven approach to the revenue cycle management of the team.
  • The negotiation between the different providers and separate insurance panels also plays a significant role in determining the reimbursement rates of the out-of-network providers and, subsequently, their revenue inflow.
  • Health data analysis firms also provide excellent in-depth insights into the market trends regarding the ‘fairness’ of the reimbursement rates. Data reports from these firms can also prove to be beneficial for the healthcare organization.
  • The administrative burden of checking the patient’s insurance eligibility lies with the out-of-network providers. Any mistake during the patient’s intake could prove to be detrimental to the billing procedure.
  • Healthcare professionals can use home-grown software solutions offered by the leading revenue cycle management companies to ensure that the procedure is smooth and devoid of any unnecessary manual errors.
  • Healthcare professionals feel it is important for the organizations to train themselves properly and stay updated on the latest regulations to avoid any non-compliance fees.
  • Staff training programs for in-house teams of billing in healthcare can also be a good practice to ensure that they know how to deal with the new No Surprises Act. It will improve revenue management on the one hand and also improve the patient communication ecosystem.

We hope this article helped you understand how you can optimize the system of billing in healthcare in your organization to accommodate the new No Surprises Act. For any queries, please write to us in the comment section below. Subscribe to our blog for more articles on healthcare, billing, technology, and management. Follow us on LinkedIn, Twitter, Instagram, and Facebook for regular updates.