The No Surprises Act, part of the Consolidated Appropriations Act of 2021, created protections against out-of-network balance billing and established an Independent Dispute Resolution process. Physicians and providers, facilities, and health plans can use IDR to resolve payment disputes for certain out-of-network charges and to determine the payment rates for those services.
When a physician, provider, or facility gets a payment-denial notice or an initial payment from a health plan for out-of-network emergency services, certain services delivered by out-of-network providers at an in-network facility (e.g., anesthesiology and radiology) the health plan, physician, provider, or facility must start an open negotiation period of 30 business days. If the health plan and physician, provider, or facility don’t agree on a payment amount in that time, either party can begin the IDR process.
The independent dispute resolution process:
NOTE:
On Jan. 1, 2022, the NSA began requiring physicians, providers, and facilities to provide good-faith estimates of charges for care to uninsured or self-pay patients (someone enrolled in a health plan who will not submit a claim).
The GFE is a notification that outlines an uninsured or self-pay individual's expected charges for a scheduled or requested item or service. CMS has provided instructions and a sample good-faith estimate template.
Generally, all physicians, providers, and facilities that schedule items or services for an uninsured or self-pay individual or receive a request for a GFE from such an individual must provide a GFE. No specific specialties, facility types, or sites of service are exempt from this requirement.
The GFE must be provided within the following regulatory timeframes:
CMS has released FAQs that address other GFE requirements, including patient notification, specific methods for delivering GFEs, changes to the scope of a GFE, storing GFEs, what happens when a GFE is incorrect, and co-provider responsibilities.
On Dec. 2, 2022, HHS delayed enforcement, pending future rulemaking, the requirement for co-physicians, co-providers, or co-facilities will be responsible for submitting specific information to the convening physician or provider within one business day of scheduling or receiving a request from the convening physician or provider.
Co-physicians or co-providers are defined as a physician, provider, or facility other than a convening provider or a convening facility that furnishes items or services that are customarily provided in conjunction with a primary item or service. In one CMS example, a patient scheduling surgery with an orthopedic surgeon can expect a GFE including an itemized list of items or services in conjunction with and including the actual knee surgery, such as:
As a co-provider, family physicians may receive requests from convening physicians, convening providers, or convening facilities that require submission of an estimate of charges if the convening physician, convening provider, or convening facility reasonably expects the FP’s services to be associated with their scheduled item or service. If a family physician’s office receives one of these requests, the physician’s office must submit its estimate back to the convener within one business day.
The NSA also introduced a requirement for Advanced Explanation of Benefits. The AEOB requirement applies to all services provided by in-network and out-of-network providers and facilities. Payers must provide AEOBs whenever an appointment is made for services and whenever requested by the patient, even without an appointment. The AEOB will be triggered by a GFE that is submitted by the physician or provider furnishing the item or service.
For every scheduled service and upon patient request, the payer must provide the patient with an AEOB that includes
To allow for the establishment of appropriate data transfer standards, enforcement of the requirement that plans and issuers provide an AEOB has been deferred. The delay postpones the requirement that a physician’s office submit a GFE to the patient’s insurance company, which would prompt the payer to provide an AEOB to the patient. However, a proposed rule on the AEOB is forthcoming that could establish provisions that would implement this requirement.
The AAFP has called for enforcement exemptions for primary care practices and other refinements to the No Surprises Act. The AAFP is deeply concerned that, once implemented, the AEOB requirements will add a much greater level of administrative burden and further diminish staff time devoted to caring for patients.