What is the No Surprise Act? The Consolidated Appropriations Act COVID-19 relief bill was signed into law on December 27, 2020. This law includes the federal No Surprise Act, which took effect January 1, 2022. Its goal is to restrict surprise or balance billing for patients. This focuses on patients that have health insurance through […]
What is the No Surprise Act? The Consolidated Appropriations Act COVID-19 relief bill was signed into law on December 27, 2020. This law includes the federal No Surprise Act, which took effect January 1, 2022. Its goal is to restrict surprise or balance billing for patients. This focuses on patients that have health insurance through their job or an individual health plan and receive emergency care or non-emergency care from out-of-network providers at in-network facilities, and air ambulance services from out-of-network providers. Medical practices will be required to provide advanced notice of out-of-network coverage for insured patients as well as good-faith estimates (GFE) for uninsured or self-pay patients.
When do these rules apply? The rules apply immediately to out-of-network emergency services provided at a hospital emergency department or independent free-standing emergency department or by air ambulance (not ground ambulance) and non-emergency care rendered by out-of-network providers at an in-network hospital (unless the patient agrees to be balanced billed).
What steps should I take? If you are a provider who is required to comply with the No Surprises Act, there are several recommended steps. Providers, defined as any health care provider who is acting within the scope of the provider’s license or certification under applicable state law, must take the following steps:
Good Faith Estimate Details The GFE must be provided electronically or in writing per the client/patient’s preference. Electronic versions must be printable and able to be saved.
The GFE must include:
The GFE must be made part of the patient record and kept for a minimum of 6 years with copies provided upon request. If errors are discovered before the service is rendered, providers or facilities must correct errors in GFEs as soon as practicable after discovery.
Resource: Good Faith Estimate Example
The American Psychological Association (APA) states, “Because psychotherapy is a reoccurring service, you can provide a GFE covering up to a year of services.” If seeing a new patient, it is acceptable to provide a GFE for the initial evaluation and then provide a subsequent GFE after that evaluation when a clearer picture emerges. Alternatively, a long-term GFE with estimates for the number of sessions, frequency of sessions, and the cost of the sessions is allowable as well. If a patient requires additional services, then the GFE must be updated and provided to the patient.
Resource: FAQs on the No Surprise Act
American Physical Therapy Association (APTA) has a Practice Advisory on the No Surprise Act requirements available to members who practice cash-based treatment or who care for the uninsured.
Resource: APTA Practice Advisory: Good Faith Estimate for Uninsured or Self-Pay Patients
The American Occupational Therapy Association (AOTA) states “while this policy applies to all uninsured patients and patients intending to be self-pay and not bill insurance, we recommend reviewing any insurance contracts in place to see if self-pay requests can be honored. CMS states, “If at any time insurance is billed, the GFE requirements do not apply.”
Resource: No Surprises Act Good Faith Estimates for the Uninsured or Self Pay Applies to Occupational Therapy Practitioners
Disputes Patients can dispute bills that exceed a certain amount through the Department of Health and Human Services.
Resources: CMS for consumers
Provider Disputes If the provider is unsatisfied with the payment amount, the provider has 30 days to initiate an open 30-day negotiation period. The Independent Dispute Review process will then go into effect during the four business days after the end of the negotiation period.
*This material is intended to be informational and educational. Each organization and situation are unique, and the information and materials on this website may or may not be applicable to your situation.