No Surprise Act Guidance
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:
- Make a disclosure publicly available, regarding the patient protections against balance billing in a clearly written sign posted in your office and on your website homepage or both.
- A model disclosure notice regarding patient protections against surprise billing is available from the Department of Health and Human Services and can be found at the links below:
- Provide the disclosure directly to commercially insured patients
- In-person, by mail, or via email, as selected by the individual
- In the language preferred by the patient
- Ask if the patient has health insurance coverage including government insurance programs like Medicare, Medicaid, CHIP, Tricare or employer-sponsored plans and whether they intend to use it. If the client/patient does not want to use their insurance or is not covered, the provider must provide a good faith estimate as outlined below.
- Inform all uninsured and self-pay patients that a GFE of expected charges is available. This includes insured patients who choose not to use their benefits.
- GFEs are not required for insured patients at this time. The Federal government has delayed the requirement for clinicians to provide GFEs to those who are insured.
- If the client/patient is not planning on using in-network insurance or is covered only by short-term, limited-duration insurance, they are entitled to receive a GFE. A GFE provides the expected charges for a scheduled or requested service, includes items or services that are reasonably expected to be provided in conjunction with such scheduled or requested item or service. That estimate must be provided within specified timeframes:
- If the service is scheduled at least three business days before the appointment date, the GFE must be provided no later than one business day after the date of scheduling.
- If a GFE is requested before the service is scheduled, the GFE must be provided within three business days. Once that service is scheduled, a new GFE should be provided.
- If the service is scheduled at least 10 business days in advance, then the GFE is due within 3 business days of scheduling.
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:
- Patient’s name
- Items or services expected to be provided by providers or facility, including procedure codes, diagnosis codes, and the expected charge.
- Clear and understandable language is required for the description of the service to be provided.
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.