As of Jan. 1, 2022, the No Surprises Act (NSA) went into effect, which is a multilayered law about preventing surprise medical bills and providing price transparency. Both independent resolution and patient-provider dispute resolution processes were created in response to possible noncompliance disputes.
This blog post includes a brief summary of the No Surprises Act and a description of the dispute resolution processes as of Jan. 24, 2022.
The No Surprises Act: A Summary
1) No surprise bills for patients with individual or group health plansThose covered by group and individual health plans are now protected (under the NSA) from receiving surprise medical bills when they receive emergency services from out-of-network providers, non-emergency services from out-of-network providers at in-network facilities and services from out-of-network air ambulance providers.
The NSA does NOT apply to health insurance coverage programs that already have protections against surprise medical billing including Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care or TRICARE.
2) Good Faith Estimates for the self-pay and uninsuredAll providers (doctors, hospitals, ASCs, MRI places, everyone) MUST provide a Good Faith Estimate (GFE) of the expected charges to any self-pay or uninsured patient no later than 3 business days after the service is scheduled (if scheduled at least 10 days in advance). If the service is scheduled less than 10 days in advance, the GFE must be given to the patient no later than 1 business day.
Providers must also provide a GFE if the self-pay or uninsured individual requests it and doesn’t schedule an item or service.
The GFE must be provided in “clear and understandable language” but CMS has outlined what information is necessary to provide on the GFE, including ICD-10 codes. (Yes, diagnosis codes for a patient that hasn’t been diagnosed yet! We recommend using the reason for visit for diagnosis codes in cases where you don’t know.)
In order for CMS to hold all providers/facilities responsible for upholding the NSA, CMS created dispute processes to help resolve out-of-network payment disputes and patient-provider dispute resolution.
The Independent Dispute Resolution (IDR) process
The IDR process established in the NSA is the way in which providers (including air ambulance providers), emergency facilities and health plans can use to resolve payment disputes for certain out-of-network charges (e.g., #1 in the aforementioned description of the NSA).
Since providers, facilities and health plans can’t balance bill a consumer for certain out-of-network services, the providers, facilities and health plans will use the IDR process to determine the payment rates for those certain out-of-network charges.
Note
To balance bill means that a patient is billed for the difference between the provider’s charge and the allowed amount (the amount set with the health plan). Healthcare.gov uses this example: If the provider’s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. The NSA protects against balance billing for emergency and some nonemergency services.
The IDR process makes sure that disputes are resolved through a third party known as a certified independent dispute resolution entity to decide the payment amount. Both sides of the dispute (provider/facility and health plan) will mutually select the certified independent dispute resolution entity, and everyone must agree to have no conflicts of interest.
After the certified entity is selected (without any conflicts of interest), the provider or facility and the health plan submit payment offers. Both provider/facility and health plan must abide by the certified entity’s decision and pay within 30 calendar days.
In order to initiate the IDR process, the provider, facility or health plan will need to use a new federal independent dispute resolution portal which will open “early 2022, after the first open negotiation periods between providers, facilities and health plans have concluded.” This means it’s likely not to be ready until at least March.
If a provider, air ambulance provider or health care facility believes a health plan isn’t complying with the IDR process, they can submit a question or complaint to the No Surprises Help Desk at 1-800-985-3059 from 8 a.m. to 8 p.m. Eastern Time. You can also go to CMS.gov.
The Patient-Provider Dispute Resolution (PPDR) process
The PPDR is a protection that consumers may use if a provider bills them at least $400 more than the expected charges on the GFE.
The PPDR process may be initiated by an uninsured or self-pay consumer or their authorized representative. Similar to the IDR process, a third party dispute resolution entity will determine payment amount, though this time it’s what the consumer will pay.
Note
The provider MUST display information in their practice about how self-pay and uninsured patients can initiate the PPDR process (e.g., call this number, go to this website).
When a consumer disputes a charge, the provider will need to provide the following:
Providers will be emailed a link to the federal dispute resolution portal (that doesn’t exist as of 24 Jan 2022) where they can upload the aforementioned documents. The dispute resolution entity will contact the provider and patient if any additional information is needed and when determination is made.
Even during the PPDR process, the provider and patient CAN continue to negotiate the bill and resolve it on their own. During this process, providers:
PPDR process information came directly from CMS.gov.
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