Americans have long worried about surprise expenses. What is surprising to few is that two-thirds of Americans say they were either “very worried” (38 percent) or “somewhat worried” (29 percent) about being able to afford their own or a family member’s unexpected medical bills. In fact, this was the expense that leads the list of expenses that Americans most worry about not being able to afford. With the new year, there are new measures to help Americans prepare for these surprise expenses. Starting on January 1, 2022, the No Surprises Act established new federal protections against these surprise medical bills. The new rules apply to nearly all private health plans offered by employers and to individuals who purchase policies through an ACA exchange.
The requirements and recommendations for adhering to the No Surprises Act are exhaustive, and fortunately there are many workflows that can be implemented to help. Consider these 5 areas when supporting the No Surprises Act requirements:
Patient Scheduling and Registration
Do your registrars collect insurance information or self-pay status when scheduling patient appointments? Or do your registrars mark patients as insured, but collect coverage information later? Do you consider absence of insurance an appropriate self-pay status?
You are likely leveraging patient estimates functionality to provide price estimates to patients for the services they will receive. Using incorrect insurance information or self-pay status when creating estimates will provide inaccurate pricing and cause unfortunate surprises for patients when they receive a bill. If you are not live on a sched/reg model, this might be the push you need to reconsider. Having accurate and complete insurance information as early as possible will lead to more accurate estimates and authorizations.
External Provider Pricing Information
Are you effectively working out of network bills?
The No Surprises Act requires that external provider price information be included in any estimates and disclosed to patients. At the same time, rarely is there a perfect system for identifying external provider costs. When you identify external provider situations, consider placing a statement hold that routes accounts to a workqueue for further investigation and follow-up. Additionally, set up your system to flag accounts for review when you bill commercially insured patients for the full amount or more than the allowed amount to systematically identify external provider situations.
Patient Communication
Have you optimized your workflows for communicating disclosures to patients and collecting written consent regarding their bills?
Balancing billing without the proper disclosures can cause unintended surprise bills for patients and leave providers at risk for fines. Per CMS guidelines, out-of-network providers cannot balance bill patients unless they have given written consent and have given up their protections. You can reference CMS’s sample notice and consent documents here. Consider integrating written consent into your patient estimate and registration workflows (via e-sign) to provide patients with the appropriate notification about out-of-network costs. Integrating disclosures and notifications into existing workflows can improve the patient’s experience and avoid overburdening them with information.
Dispute Resolution
Do you have a workflow in place for when a patient files a complaint?
You should consider the possibility that a patient will receive a surprise balance bill and file a complaint with CMS. Should this happen, prepare to respond by establishing workflows to track, monitor, manage, and resolve the dispute. These workflows should address identifying the appropriate patients via an indicator, triaging them for review in a workqueue, identifying the staff that will be responsible for follow-up, creating adjustment codes and processes for resolving the balance, and reporting on the financial impact.
Operational Readiness
Is your organization prepared to maintain your No Surprises workflows?
Parts I and II of the No Surprises Act are the beginning of a comprehensive set of rules from CMS that provide transparency to patients regarding their medical bills. Already a third interim final rule has been issued and is open for public comment regarding prescription drug spending. We recommend establishing a governance structure that can effectively monitor the effectiveness of your No Surprises workflows and can appropriately review and react to new regulatory requirements that come down the road.
These considerations are just the beginning of your journey towards optimizing your system to support the No Surprises Act. The most important step you can take right now to be successful with supporting the No Surprises Act is to ensure you have a strong governance structure with assigned roles and responsibilities. Having a strong governance structure will enable your organization to properly respond to unexpected issues, continue improving existing workflows, and react swiftly to regulatory changes. If you need help with establishing this governance group or any of the steps mentioned in this post, please reach out to us here at The Wilshire Group and allow our team of professionals to assist you in finding success with the No Surprises Act.
