Aug 12, 2022

No Surprise Act Makes RCM More Important Than Ever

Home » No Surprise Act Makes RCM More Important Than Ever

When any new federal regulations go into effect, there is always trepidation and many, many questions. Even though detailed requirements are spelled out, just how the new procedures and requirements will impact the bottom line of those affected is always a question, especially when the subject is medical billing laws.
When the No Surprises Act effective date of January first arrived this year, that was certainly the case. New forms requiring patient signatures had been provided and rules had been put in place to protect patients from receiving unexpected medical bills. While no health care provider wants to be the one to deliver a shocking bill to a patient, payment still must be collected, and the new law means dealing with insurers in new ways.

The No Surprises Act Impact on Providers

The focus of the act is out-of-network charges, so it has the greatest impact for facilities with providers who deliver services to patients through another organization, such as a specialist at a hospital who is not on the staff.

Out-of-network providers do not have the same negotiated rates that insurers and in-network providers have agreed to. When a patient goes to a facility that is in their insured network, they expect all services to be covered, so out-of-network providers in this situation are a common source of surprise bills.

Another major area of impact is emergency care. When people traveling away from home require emergency care, the local facilities are often not in their insurer’s network. Since out-of-network rates are generally much higher, patients have had to pay the difference. The No Surprises Act only allows patients to be billed for in-network rates for most emergency care.

While this includes air ambulance services, the one major exception to the act is ground ambulance transport.

In addition to patients out of network, the new regulations also affect some self-pay and uninsured people. Because there are so many variables in the billing process under the Act, it may become feasible for more practitioners to look into outsourced billing and payment services.

One of the major changes that practitioners have experienced has been the reduction of in-office visit billing options. The No Surprises Act requires that Medicare and Medicaid pay for all services provided within a physician’s office, requiring the use of an EHR to accurately capture all billable information.

The No Surprises Act also affects the reimbursement structure of physicians. The legislation requires that Medicare and Medicaid pay a lower rate for services performed in an office setting, regardless of the physician’s level of education or training. The legislation also sets a maximum allowable amount of fees that can be charged to Medicare and Medicaid for office visits.

It requires providers to give patients an estimate of the cost of care before they undergo treatment. This information must be accurate within 20% of the final bill.

The Law Is Meant to Increase Revenue Transparency

While the No Surprises Act adds revenue challenges for practitioners, it is seen as a major victory by consumer advocates who have long argued that patients should be able to shop for health care services the same way they shop for other goods and services. They believe that this will help to drive down health care costs by encouraging providers to compete for business.

Much of the change in the process occurs at the beginning of the revenue cycle. The act requires hospitals and physicians to give patients a list of their expected out-of-pocket costs before they receive treatment. It also prohibits providers from billing patients for unanticipated costs after services have been rendered.

One of the major changes that practitioners have experienced has been the reduction of in-office visit billing options. The No Surprises Act requires that Medicare and Medicaid pay for all services provided within a physician’s office, requiring the use of an EHR to accurately capture all billable information.

Billing Communication With Patients Must Be Clear and Up Front

Previously, providers were able to bill full “list” rates for out-of-network specialists such as anesthesiologists and radiologists, which resulted in much higher revenue, but upset unsuspecting patients who expected their insurance to pick up much more of the costs.

During the process of developing the new law, “benchmark” payments equal to the median in-network rate were suggested as the allowable charge. Provider groups were concerned that that would allow insurers to set the prices they would pay, thus greatly reducing provider revenue. Arbitration is the solution that became part of the final version of the Act, and the specifications include several factors that were demanded in support of providers.

The act has had a significant impact on the revenue cycle for laboratories, as they now need to ensure that their claims are processed and paid as quickly as possible. In order to meet these new requirements, many laboratories are turning to revenue cycle management (RCM) solutions that can help them automate their billing processes and improve their cash flow.

Most Changes Take Place at the Beginning of the Medical Revenue Cycle

A high percentage of the work required to comply with the No Surprises Act happens early on, before the patient is even seen. Uninsured patients must be given a good faith estimate of costs, and the final bill must be within 20% of that amount.

Billing for services by out of network practitioners requires confirming the patient’s insurance, verifying that the practitioner is out of network and what their rate is. Then the patient must be given the amounts and the proper forms to sign.

A signed agreement must be obtained before services are given in order to bill a patient more for out of network providers than their insurance’s covered rate. There are also some new reporting requirements in addition to the payment negotiation and potential arbitration participation.

Help for Patients Is Available

Since the purpose of the Act is to help consumers, CMS has a page right on the website where consumers can file a complaint online or get the phone number to call in with questions or complaints. The support staff can’t adjust payments or give legal advice, but they are there to review the complaint to make sure that the insurance company and provider/medical facility has followed the new billing rules. They also investigate and enforce federal policies and laws and look for patterns of problems.

Medcare MSO is an experienced revenue cycle management company. Our proven system for managing claims not only takes on the workload of billing but has also increased revenue for our clients. In addition to the billers, we have a dedicated team that is ready to take over any aspects of RCM where you need support. They are prepared to take on scheduling, preapprovals, insurance verification, credentialing and all the other administrative revenue management tasks that are critical to your success, but too time consuming to do yourself. Give us a call today at 800-640-6409 to discuss how we can work together.

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