Best Practices to Stay in Compliance with the No Surprises Act

The Vice President of Connected Care at HST Pathways explains the No Surprises Act and best practices to help surgery centers stay compliant.

On January 1, 2022, the No Surprises Act (NSA) took effect across the nation after bipartisan approval from Congress in December 2020. This new law establishes several requirements to enhance patient rights and eliminate surprise healthcare billing.

Through the NSA, surgery centers are considered “convening providers,” which means someone must coordinate how to obtain the cost for all providers working on a patient and show that estimate to the patient. 

This Good Faith Estimate (GFE) currently needs to be provided to self-pay and uninsured patients but will eventually expand to all patients. It must also be delivered in a timely manner, within one day of a procedure scheduled out three days. Any add-ons must be disclosed three hours in advance of the procedure. These estimates become part of medical records and must be retained for seven years. They are also significant in the case of any Independent Dispute Resolution (IDR) processes.

Patients have the right to dispute any bill $400 over the GFE, and if parties cannot reach a settlement in a defined period of time, it will then be assigned to an arbitrator.

There are several other aspects when it comes to being compliant with the NSA. The Centers for Medicare and Medicaid Services offers several models on its website of how to disclose this new act to patients and requires this disclosure be published physically and on ASCs’ websites. Beyond that, facilities should also add self-pay and out-of-network cost estimate calculators.

Providers now will be required to use in-network benefits for out-of-network patients. These patients should be aware of the Qualifying Payment Amount (QPA) within their given region, which leads to a reasonable amount of median contracted rate for in-network reimbursement for certain procedures. ASCs can still balance bills, as long as patients sign a waiver of patient rights.

Overall, this new act expands the responsibilities of payors and providers and encourages price transparency within the healthcare community. Some of these changes might be more difficult to handle, so Scott Palmer, Vice President of Connected Care at HST Pathways, provided a 10-Step Action Plan to help best comply to the NSA:

  1. Educate staff
  2. Post CMS model
  3. Update payor directories
  4. Review and update chargemaster
  5. Connect with co-providers about how to communicate expected charges to patients
  6. Verify each patient’s insurance
  7. Use in-network benefits for out-of-network patients
  8. Provide GFE
  9. Provide disclosure of patient rights
  10. Embrace price transparency

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