No Surprises Billing Act: Updates and Overview

The No Surprises Billing Act went into effect on January 1, 2022. A major provision of the bill is the Good Faith Estimate (GFE), designed to protect uninsured or self-pay patients from unexpected, costly medical bills. If the individual does not have health insurance or plans not to use insurance, the individual is eligible to receive a GFE of what they may expect to be charged for the visit or procedure prior to receiving the service. The provision allows for a patient to also request a good faith estimate at any time.

The Centers for Medicare and Medicaid Services (CMS) released its final rule that includes timelines for when the patient is entitled to receive a GFE. It can depend greatly upon the patient's insurance status, the provider's insurance network status, and the type of care and location of the service.

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The provider or facility must determine if the patient is eligible for a GFE by asking the individual if they are part of the following:             

       A group health plan

       Group or individual health insurance coverage offered by a health insurance issuer

       A federal healthcare program

       A health benefits plan under a Federal Employees Health Benefits (FEHB) Program

If the individual is not enrolled in any of the above mentioned, then they are considered self-pay and are entitled to a GFE. As part of the rules on GFE, a new Patient-Provider Dispute Process (PPDR) has also been put in place that is available to uninsured or self-pay individuals who receive a bill that is substantially more than the expected charges provided in the Good Faith Estimate.

       The No Surprises Act applies to most plan types

       Balance billing may be prohibited based on plan type

       A Good Faith Estimate must be provided to uninsured or self-pay patients prior to office visit timing based on when appointment is made

       Notice and consent can be signed by patient to waive protections for balance billing in exchange for provision of services (time guidelines applicable)

For more information on the No Surprises Act, visit:
https://www.cms.gov/nosurprises

A sample Good Faith Estimate template may be found at:
https://www.cms.gov/files/document/good-faith-estimate-example.pdf

Good Faith Estimate FAQs:
https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/G...

For inquiries relating to the No Surprises Act, members may contact Andie Tena, CAP’s Director of Practice Management Services, ATena@CAPphysicians.com or at 213-473-8630.   

 

Andie Tena is CAP’s Director of Practice Management Services. Questions or comments related to this column should be directed to ATena@CAPphysicians.com.