ASC RCM Quick Tips: Understanding the No Surprises Act

By Angela Mattioda, Vice President of Revenue Cycle Management Services

Effective Jan. 1, 2022, there will be additional provisions to the No Surprises Act. There are several useful tools that can help you understand the requirements and new provisions to better ensure you are following the rules.

The No Surprises Act was passed by Congress in December 2020. It went through three interim provisions in 2021 that will be applied for 2022. Two of the provisions are directly related to ASCs.

The three provisions are as follows:

• On July 1, 2021, part 1 of the interim final rule was issued. It restricts surprise billing for patients in employer-based and individual health plans who receive care from out-of-network providers at in-network facilities.
• On Sept. 30, 2021, part 2 of the interim final rule was issued. It establishes additional provisions to protect patients, including:
  • establishing an independent dispute resolution process that will determine out-of-network amounts between providers and facilities;
  • requiring good faith estimates for cash patients;
  • establishing a patient/provider dispute resolution process for cash patients; and
  • providing patients with a way to appeal certain health plan claims processing.
• On Nov. 17, 2021, part 3 of the interim final rule was issued. It concerns prescription drugs.

Key Takeaways for ASCs

Here are three topics ASCs should understand concerning how the No Surprises Act affects them.

1. Disclosure — ASCs must disclose balance billing protections and how to report violations. Disclosures must be posted at a prominent location at the ASC and on its website, and ASCs should provide the disclosure to patients. You can find the requirements and sample disclosures here.

2. Consent — If a physician involved in the surgery (surgeon/anesthesiologist) is out of network, it is incumbent upon the ASC to ensure there is an arrangement of notification to and consent from a patient within the timeframe required.

3. Dispute resolution — Within the information provided to patients, there should be steps outlined to guide them if they need to file a dispute.

CMS has published a helpful document that outlines the above takeaways plus additional key takeaways for ASCs and providers.

What Does the No Surprises Act Do?

Let's step back and look at some of the most important rules under the No Surprises Act. The legislation does the following:

• Bans surprise billing for emergency services. Out-of-network services must be covered at an in-network rate without requiring prior authorization.
• Bans balance billing and out-of-network cost-sharing for emergency and certain non-emergency services. The patient’s cost for out-of-network services cannot be higher than if the services were provided by an in-network provider, and any coinsurance or deductible responsibility must be based on in-network provider rates.
• Bans out-of-network charges and balance billing for ancillary care by out-of-network providers at an in-network facility.
• Bans certain other out-of-network charges and balance billing without advanced notice. Facilities must provide patients with prior notice that a service(s) is out of network and secure patient consent to receiving care on an out-of-network basis before the patient is billed for the service(s).
• Holds patients liable only for their in-network cost-sharing amount while also giving providers an opportunity to negotiate reimbursements.

The best way to sum up the act is that it will be illegal to bill patients for more than in-network rates if the patient did not consent to receiving services by an out-of-network provider associated with the treatment. For example, if a patient receives care at an in-network ASC with an in-network surgeon but the anesthesiologist is out of network, the No Surprises Act will protect the patient from getting billed a higher rate for out-of-network care by the anesthesiologist.

The No Surprises Act aims to increase transparency to help patients better understand their cost liability prior to receiving services. Good faith estimates must identify whether the provider is in network, and if not, how to find in-network providers. CMS has published information on providing good faith estimates here.

If patients are billed for an amount exceeding the good faith estimate, they have options to file a dispute. Learn more about payment disputes here.

Lastly, healthcare payments company Zelis released an on-demand webinar that provides an overview of the No Surprises Act and other information about the legislation you may find helpful.