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
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