The No Surprises Act went into effect on January 1, 2022. The Act is intended to protect healthcare consumers from surprise medical bills. While many of the provisions in the Act are focused on creating transparency between healthcare providers and facilities, there are provisions that will impact health plans. It’s important to know what the No Surprises Act means for your health plan.
No Surprises Act Overview
CMS has published extensive training to help providers and health plans understand and comply with the No Surprises Act. As with all things, understanding the regulations and complying are two different things. In pursuit of protecting patients from surprise medical expenses, the Act outlines several specific areas for providers and insurers to implement greater transparency.
- Balance billing is prohibited in certain situations for patients with insurance coverage. This keeps providers from billing members the difference between billed amounts and covered charges plus patient liability.
- Requires providers and facilities to provide good-faith estimates for uninsured/self-pay patients and to submit good-faith estimates in certain situations to patients’ insurers.
- Creates a dispute resolution process for patients to dispute charges that are substantially different from the good-faith estimate.
- Limits patients’ financial responsibility when a provider changes network status (continuing care) with their insurer during treatment or when they act on incorrect provider directory information.
It’s this last point that has a significant impact on health plans. Let’s take a closer look.
Provider Directory Provisions
The provider directory provisions of the No Surprises Act place responsibility on both providers and health plans. This reinforces CMS’ general approach of expecting providers and health plans to collaborate closely to ensure accurate information in provider directories.
Providers and healthcare facilities will be required to refund patients – with interest – if the patient is billed and pays for charges beyond the in-network costs. Additionally, it requires providers to establish processes to maintain accurate provider directory information with each insurer that they are contracted with.
It does allow providers to contractually require health plans to remove their information from provider directories promptly upon contract termination. Additionally, providers can contractually require health plans to bear financial responsibility for any charges that result from inaccurate directory information.
While specific rulemaking is anticipated this year around provider directory provisions, providers must make good-faith efforts to comply by January 1, 2022.
Provider Directory Information
Providers must share specific information with their contracted insurers. This information will help payers to maintain accurate directories. This new regulation encourages providers to provide prompt and accurate information to health plans.
- Names and contact information, including digital contact information (e.g., email addresses)
- Specialty information
- Locations
- Details of each medical group, clinic, and facility in any of the networks for which the provider is contracted
Health Plan Financial Impacts
Under the No Surprises Act, health plans must limit a member’s cost-sharing responsibility in cases where the member acts on incorrect provider directory information. Additionally, cost-sharing terms must be in line with the in-network rates in these instances.
For example, a member receives treatment from a provider that they believe – based on the plan’s provider directory – to be in-network. Because the health plan did not remove the provider from their directory in a timely manner, it results in the member incurring Point of Service costs. The member may now be charged for a deductible and co-insurance as opposed to a simple co-payment had the provider truly been in-network. In these instances, the patients’ responsibility is limited to the in-network co-payment. The provider also cannot bill the member for more than the in-network cost-sharing amount.
Complying With the No Surprises Act
Health plans have an uphill battle with provider directory information. The No Surprises Act introduces requirements intended to foster better collaboration and information sharing between plans and providers. In order to achieve compliance, health plans should:
- Establish contractual terms that providers must share changes in network status promptly
- Encourage the use of a common roster format across all provider groups where possible to ensure all required information is provided
- Leverage provider directory systems that can track when changes to the directory were made and published for audit purposes
- Automate the removal of providers from directories upon contract termination
- Require providers to update and certify their NPPES records routinely
- Regularly audit provider directories and rosters through automated and manual methods including email and phone outreach
- Capture and categorize member grievances and disputes related to provider directory or out-of-network cost sharing issues. Use this data for root cause analysis and process improvement
Health plans have long struggled to maintain accurate and current provider information. The No Surprises Act puts financial consequences in place for failure to do so. On the flip side, it gives health plans and providers a clear path forward in terms of information sharing.
If your plan is struggling to maintain accurate information, Maven One can help. From roster intake and scrubbing to provider publishing to proactive directory audits, our platform and services offer comprehensive solutions to comply with the No Surprises Act.