As of Jan. 1, 2022, the No Surprises Act (NSA) went into effect, which is a multilayered law about preventing surprise billing and providing price transparency. Both independent dispute resolution and patient-provider dispute resolution processes were created in response to possible noncompliance disputes.
This blog post includes a brief summary of the No Surprises Act and a description of the dispute resolution processes as of Jan. 24, 2022.
Those covered by group and individual health plans are now protected (under the NSA) from receiving surprise medical bills when they receive out-of-network emergency services from out-of-network providers, non-emergency services from out-of-network providers at in-network facilities, and services from out-of-network air ambulance providers.
The NSA does NOT apply to health insurance coverage programs that already have protections against surprise medical billing, including Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care, or TRICARE.
All providers (doctors, hospitals, ASCs, MRI places, everyone) MUST provide a Good Faith Estimate (GFE) of the expected charges to any self-pay or uninsured patient no later than 3 business days after the service is scheduled (if scheduled at least 10 days in advance). If the service is scheduled less than 10 days in advance, the GFE must be given to the patient no later than 1 business day.
Providers must also provide a GFE if the self-pay or uninsured individual requests it and doesn’t schedule an item or service.
The GFE must be provided in “ clear and understandable language ” but CMS has outlined what information is necessary to provide on the GFE, including ICD-10 codes. (Yes, diagnosis codes for a patient that hasn’t been diagnosed yet! We recommend using the reason for visit for diagnosis codes in cases where you don’t know.)
In order for CMS to hold all providers/facilities responsible for upholding the NSA, CMS created dispute processes to help resolve out-of-network payment disputes and patient-provider dispute resolution.
The independent dispute resolution process established in the NSA is the way in which providers (including air ambulance providers), emergency facilities, and health plans can resolve payment disputes for certain out-of-network charges (e.g., #1 in the aforementioned description of the NSA).
Since providers, facilities, and health plans can’t balance bill a consumer for certain out-of-network services, they will use the federal independent dispute resolution process to determine the payment rates for those charges.
The IDR process ensures disputes are resolved through a third-party known as a certified independent dispute resolution entity to decide the payment amount. Both sides (provider/facility and health plan) will mutually select the certified independent dispute resolution entity, ensuring no conflicts of interest.
If a provider, air ambulance provider, or health care facility believes a health plan isn’t complying with the IDR process, they can submit a question or complaint to the No Surprises Help Desk at 1-800-985-3059 from 8 a.m. to 8 p.m. Eastern Time. You can also go to CMS.gov.
Note
To balance bill means that a patient is billed for the difference between the provider’s charge and the allowed amount (the amount set with the health plan). Healthcare.gov uses this example: If the provider’s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. The NSA protects against balance billing for emergency and some nonemergency services.
The PPDR is a protection that consumers may use if a provider bills them at least $400 more than the expected charges on the GFE.
The PPDR process may be initiated by an uninsured or self-pay consumer or their authorized representative. Similar to the IDR process, a third party dispute resolution entity will determine payment amount, though this time it’s what the consumer will pay.
The provider MUST display information in their practice about how self-pay and uninsured patients can initiate the PPDR process (e.g., call this number, go to this website).
When a consumer disputes a charge, the provider will need to provide the following:
The original GFE they provided their patient.
The bill they sent to their patient.
Any supporting documents that help to explain why the bill is higher than the estimate.
Providers will be emailed a link to the federal dispute resolution portal (that doesn’t exist as of 24 Jan 2022) where they can upload the aforementioned documents. The dispute resolution entity will contact the provider and patient if any additional information is needed and when determination is made.
Even during the PPDR process, the provider and patient CAN continue to negotiate the bill and resolve it on their own. During this process, providers:
May NOT move the bill to collections or threaten to do so.
MUST pause collections if the bill is already in collections.
Can’t collect late fees on unpaid amounts.
Can’t threaten to take any retaliatory action against the patient for initiating the PPDR process.
PPDR process information came directly from CMS.gov .
Note
The provider MUST display information in their practice about how self-pay and uninsured patients can initiate the PPDR process (e.g., call this number, go to this website).
For out-of-network providers, the No Surprises Act has significantly changed how payment disputes are handled. Prior to the NSA, providers could engage in balance billing, charging patients the difference between the contracted rate and the provider’s billed amount. Now, out-of-network providers must resolve these disputes through the independent dispute resolution process rather than directly billing the patient.
The law applies to a wide range of services, including emergency services, non-emergency services provided at in-network facilities, and air ambulance services. When a provider offers out-of-network services, they must use the IDR process if there is a disagreement about the cost-sharing amount or payment rates with health insurance issuers.
One of the key provisions of the No Surprises Act is the requirement that both parties—the provider and the health plan—submit their proposed payment amounts to a certified IDR entity. The entity then decides the appropriate payment based on the qualifying payment amount (QPA), market share, and other relevant factors. The federal independent dispute resolution process ensures that disputes are settled fairly and without bias.
If a provider feels that a health insurance issuer has not complied with the NSA, they can escalate the matter through the federal government or seek assistance from the departments of Health and Human Services (HHS). Providers are protected under the law from retaliation and can report non-compliance through official channels like the No Surprises Help Desk.
This new regulatory environment has also brought more transparency to health care billing, with clear billing protections for patients and clear guidelines for providers to follow. Out-of-network providers are now required to work within the constraints of the federal independent dispute resolution process to ensure fair reimbursement while upholding the patient protections established by the NSA.
The No Surprises Act (NSA) shields patients from surprise billing by out-of-network providers for certain medical services, including emergency services and non-emergency services at in-network facilities. Prior to the NSA, patients were often subjected to balance billing, where they were responsible for the difference between what their health plan covered and the provider’s charges. Now, patients are only responsible for their in-network cost-sharing amounts, even when treated by out-of-network providers.
If a payment dispute arises between out-of-network providers and health insurance issuers, the law requires the use of the independent dispute resolution (IDR) process. Before initiating the federal IDR process, the disputing parties must engage in an open negotiation period. If no agreement is reached, a certified IDR entity reviews the case, considering factors like the qualifying payment amount (QPA) and state law. The decision is binding, and both parties must comply within 30 business days.
These protections extend to services like air ambulance transport, a common source of surprise billing before the NSA. By standardizing how out-of-network services are billed and resolving disputes through an arbitration process, the NSA ensures that patients are not burdened with unexpected costs.
The federal government, including the departments of Health and Human Services (HHS), Labor, and the Treasury, oversees enforcement, making the NSA a crucial safeguard in health care billing.
The No Surprises Act has significantly transformed the landscape of health care billing by protecting patients from unexpected costs due to out-of-network services. Through the implementation of the independent dispute resolution (IDR) process, the law ensures fair resolutions of payer disputes between health insurance issuers and out-of-network providers. This has brought much-needed transparency to the system, particularly for high-cost services like air ambulance services and emergency services. With clear billing protections in place, patients can now focus on their care without the worry of excessive medical bills.
Discover how Rivet’s tools help you navigate out-of-network payments and comply with the No Surprises Act. Request a demo today to learn how our solutions streamline the federal IDR process and safeguard your practice’s revenue.
1. What is the No Surprises Act?
The No Surprises Act is a federal law aimed at protecting patients from unexpected medical bills for emergency and non-emergency services from out-of-network providers.
2. What is the independent dispute resolution (IDR) process?
The IDR process is a method for resolving payment disputes between out-of-network providers and health plans, without balance billing the patient.
3. What services are covered under the No Surprises Act?
The No Surprises Act covers out-of-network emergency services, non-emergency services at in-network facilities, and air ambulance services.
4. Can patients be balance billed under the No Surprises Act?
No, patients cannot be balance billed for emergency or certain non-emergency services under the No Surprises Act.
5. How long does the independent dispute resolution process take?
The IDR process typically concludes within 30 calendar days after the certified dispute resolution entity makes a decision.
6. Who can initiate the IDR process?
Providers, facilities, and health plans can initiate the IDR process for disputes involving out-of-network payments.
7. What is a Good Faith Estimate under the No Surprises Act?
A Good Faith Estimate provides self-pay and uninsured patients with an estimated cost of medical services before they receive care.
8. How can health care providers submit disputes under the No Surprises Act?
Providers can submit disputes through the federal independent dispute resolution portal or by contacting the No Surprises Help Desk.
9. Does the No Surprises Act apply to all health insurance plans?
No, the No Surprises Act does not apply to health insurance programs that already have protections, such as Medicare, Medicaid, and TRICARE.
10. What happens if a provider does not follow the No Surprises Act?
Providers who do not comply with the No Surprises Act may face penalties, and patients can dispute charges through the patient-provider dispute resolution process.
Rivet offers software solutions that integrate with your EHR for up-front patient cost estimates (that comply with the 2021 No Surprises Act), as well as denied and underpaid claim solutions.
To see a quick one-page synopsis of how our estimates comply with the Good Faith Estimate, click the button below for a free PDF.
To see Rivet's Estimates and discuss billing pain points, request a demo below.
