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Understanding the No Surprises Act in 2022

Wondering with the No-Surprises-Act means for your practice? Check out this blog to learn more!

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Understanding the No Surprises Act in 2022

The No Surprises Act was signed into law in December 2020 under the Consolidated Appropriations Act of 2021. The No Surprises Act addresses unexpected gaps within patient insurance coverage that could result in surprise medical bills for the patient. Moving forward, healthcare providers must also issue a good faith estimate to uninsured or self-pay patients seeking medical services.

To avoid surprises in compliance in 2022, learn more about the No Surprise billing legislation and the subsequent good faith estimate requirements below.

What is the No Surprises Act 2022?

The No Surprises Act 2022 protects patients from unexpected medical bills in the event they unknowingly receive medical care from an out-of-network provider. These regulations commonly pertain to patients who received emergency services, air ambulance services, and various out-of-network providers who operate in an in-network facility.

With the No Surprises Act effective as of January 1, 2022, all healthcare providers — especially therapy providers — must understand the implications of these new provisions. In addition to insured patient protection, the No Surprises Act 2022 also requires health care providers to provide a good faith estimate to uninsured and self-pay patients for the cost of their services.

The Centers for Medicare and Medicaid Services (CMS) considers any physician or healthcare provider who operates within the scope of practice of their license, including physical therapists and physical therapists assistants, to be subjected to this provision. Therefore, the majority of providers in outpatient therapy settings must remain mindful of surprise billing legislation.

What Does the No Surprises Act Cover?

The No Surprises Act protects insured patients from receiving unexpected medical bills after receiving medical services from a clinician who was unknowingly out-of-network. The No Surprises legislation also created a payment dispute resolution process between insurance providers and healthcare providers for instances in which a patient was out-of-network.

The No Surprises Act goes hand-in-hand with balance billing, or when a provider bills a patient for the difference between the costs of the medical service and the amount allowed under insurance coverage. For instance, if a provider charged $1,000 and insurance only covered $500, the patient would be billed for the remaining $500.

To help avoid these unexpected (and unpleasant) surprises, the No Surprises Act 2022 banned surprise medical bills for most emergency services, out-of-network charges and balance bills for certain additional services, and out-of-network cost-sharing. Providers must also present insured patients with an easy-to-understand notice explaining the applicable billing protections.

The No Surprises Act also created additional provisions for uninsured and self-pay patients, namely the introduction of good faith estimates. Moving forward, uninsured patients and self-pay patients must understand how much care will cost before they receive it via these estimates. Here’s how these estimates might impact therapy providers.

What are Good Faith Estimate Requirements?

Good faith estimate requirements mandate that healthcare providers list expected charges and any included discounts in the form of a cash pay rate or payment rate set by the provider for uninsured or self-paying patients. The good faith estimate amount may also be listed as the amount a clinician would expect to bill an insurance provider if the patient possessed insurance coverage. 

For clarity, the law views this amount as only an estimate where the actual cost of medical services may differ from what was originally listed under the good faith estimate. However, under new regulations, if that final cost amount is substantially higher ($400 or more) than the good faith estimate, new patient dispute resolution processes allow individuals to challenge this amount. 

Outside of the final cost estimate, there are also additional components that must be encompassed in a good faith estimate. These components include but are not limited to patient name, birth date, description of service, and diagnosis codes.

Good faith estimate requirements are also contained to a particular time frame. If an appointment for services is made three or more business days in advance, the estimate must be provided within one business day after the appointment is scheduled. For appointments made 10 business days or more in advance, a provider has up to three business days after scheduling to provide an estimate.

Who Does the No Surprises Act Apply To?

All healthcare providers are subjected to the various new regulations under the No Surprises Act 2022, including physical therapists, occupational therapists, and speech-language pathologists. According to CMS, the term “healthcare provider” refers to any physician or healthcare provider who acts within the scope of practice of that provider’s license or certification under applicable state law.

Provider types under such terminology include but are not limited to physical therapists, cardiologists, and gastrologists. No Surprises Act regulations also pertain to various medical service types, including emergency service, air ambulance services, anesthesiology, and radiology.

What Steps Do I Need to Take and When?

As a physical therapy provider, you may be left asking what steps you should take regarding the new regulations implemented under the No Surprises Act 2022. With these new regulations having gone into effect on January 1, 2022, the answer for when to take action is now.

Under good faith estimate requirements, providers must post a Notice of Availability of Good Faith Estimates inside their office and on the practice’s website regarding any scheduling or questions regarding costs. When a patient requests physical therapy services, providers should determine whether they are uninsured or choosing to self-pay at the time of scheduling.

If a patient is uninsured or self-paying, a provider must deliver the good faith estimate orally and in the form of written copy using mail, email, or other electronic means that can be converted to physical print (such as a patient portal via an EMR). Be sure to also abide by the previously mentioned time frames in which a patient must receive their good faith estimate.

Useful Resources for Physical Therapy Providers

As you continue to navigate the various new regulations put in place under the No Surprises Act, remember that there are numerous resources readily available to help guide the way. Here are some of the top resources for physical therapy providers regarding the No Surprises Act 2022:

The Bottom Line

Now that you’re equipped with a No Surprises Act summary, you might be wondering which steps to take next. To avoid compliance issues, PT providers will want to remain up-to-date with the new good faith estimate requirements and payment dispute resolution processes established under the No Surprises Act. MWTherapy’s EMR and Billing features are here to help.

With our advanced software suite, providers can easily track good faith estimates and accompanying patient data from one robust platform. Stay on top of when patients schedule an appointment to deliver estimates in a timely fashion. Maintain a record of which patients are insured — and their coverages — to avoid surprises in 2022. Book a demo today.

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