No Surprises Act Overview: Best Practices for Compliance

Introduction to the No Surprises Act

Hello. This is Jonathan Wiik at FinThrive, and I'm giving an update on the No Surprises Act.

The start by saying care and payment aren't equal. It's really why you're seeing such legislative and I would argue public sentiment surrounding the, feelings that folks have, and financial impact surrounding bills.

Health care often has good outcomes for folks from a clinical standpoint, but when they get the bill, it's another story. And so the No Surprises Act really came out of folks having some understanding and and more importantly, I guess, protections from bills that come from third parties primarily in terms of balance billing and being surprised by those amounts as they're often out of network and reflect bill charges.

I took this picture. I was at the White House about four or five years ago.

That is senator or secretary Becerra there, over the health and human services. That is now Robert Kennedy junior, holds that position. But he said that no one should forego care out of fear for surprise billing.

And health insurance should offer patients a peace of mind, and they remain committed to ensuring transparency and affordable care. And I know the Trump administration is also very committed. This is a bipartisan issue surrounding protecting consumers from bills that are, to some extent inflated, just because of the insulation surrounding an insurance contract. As I mentioned, there's a lot of pressure, and this has continued over time, from consumers about coverage and costs, high deductible health plans as more out of pocket shifts, legislative pressures. There's a lot of transparency, regulation, enforcement, those types of things happening now as well.

Chapter
The Need for Transparency in Healthcare Costs

Let's talk transparency for a minute. I don't think you know, I don't I don't wanna compare a rehab facility or a hospital necessarily to a, you know, a grocery store. But nonetheless, it's a pretty opaque environment. The costs for most health care services are not posted, at least in a way of out of pocket. They may be posted in terms of charges. The coverage is also highly variable depending on how things are known and what's going on.

As these rules come out to help kinda make that more transparent, you really gotta think about what that looks like just operationally. And part of what we'll talk about today is these three rules and and where we're at. They're not new.

I think when I was approached to kinda put this together for you, I raised a brow a little bit because, no, surprise, medical billing actually came out about almost two and a half years ago. So it's pretty pretty, old, I would argue, or established legislation. Is it constantly moving? Yes. You will certainly hear about it now. Price transparency, you know, started out of the ACA. Enforcement really started about four years ago in January.

There's million dollar fines. Now there's about nineteen or so hospitals that have actually been kinda dinged by that first column. We'll talk about surprise medical billing today or out of network bills. The fine structure is not there and then payer price transparency. Sometimes I hear that could be called, transparency and coverage or tick t I c, just went into place about two years ago, and it's been phased into last year a little bit. You'll hear about these AEOBs or advanced evidence of benefits, whether we're we're a provider or or be a facility or physician or a hospital actually talk to an insurance company beforehand, all the providers, and they kinda quarterback an estimate.

That's been put on hold because it's frankly too difficult to administer.

Chapter
Statistics on Surprise Medical Bills

Why does the act exist? Well, about forty one percent of insured adults are, you know, surprised by a medical bill. Eighteen percent of those are emergency visits. That's probably the most predominant area. Twenty one percent of surgeries, sixteen percent anesthesiology. I would argue imaging or x-ray is also in that list quite a bit.Thirty three states right now have enacted laws already. Hawaii is not one of them.

But, there there aren't any balanced billing protections there. But in the state statute, you might see those coming later. But the this was really meant at the federal level to put in a in a rule where there is not a state rule in place. And equally kind of interesting is if there is a state rule in place, it actually takes precedent over the federal rule. This was really to help kind of bridge the gap between something called a RISA. There's some exemptions that surround there with tax exemptions and how insurance works and those types of things. But this was to make sure there weren't any loopholes for folks that had ERISA plans in their states and didn't have to follow, the state law.

Chapter
Federal vs. State Regulations on Billing

This federal law supersedes that and, and now takes precedent if there's in the absence of a state law.

Timeline here. I'm not gonna go through all the details, but, there are two iterations of this rule that happened in twenty one and twenty two.

Right now, the payer transparency and coverage things are getting implemented as of last year.

It affects any patient who had emergency medical care. That's probably the biggest thing if you think about that with the no surprises act because it's primarily focused on emergency services. That's where the spirit of it came out of it. It does impact other services, but I will go over the rule here in a minute.

But, basically, under any circumstance, you cannot balance bill for emergency care anymore, at all. The a a g s GFE, we'll talk about that in a second, but the good faith estimate has to be provided. They have to be screened for charity. If they're self pay, if they have insurance, they have to be afforded the in network rates and those types of things.

And that's kind of the biggest deal.

Air ambulance falls under that as well. Stabilization of the post medical stabilization exam. Out of network services at an in network facility, must be provided at that rate or something called reciprocity, if that makes sense. It really is two different laws.

There's a protection against the bill itself, and then there's also this good faith estimate. We'll walk through each one of these, but I've kind of covered really the protection against the bill. It's that you can't bill the difference between what the insurance didn't pay or in lack of insurance. You can't bill charges, has those things.

Commercial health insurance, may also not, be in place for, certain situations. They may only have, you know, maybe a a a, indemnity plan and those types of things. Regardless, in an emergency set setting, you cannot bill charges to a patient anymore. That that that's kind of the crux of what we'll talk about today.

There's also many, many rules surrounding notices, displays, postings, those types of things. A good faith estimate really is the piece that talks about the uninsured and self pay patients, and those are required now, across all service lines.

They establish price transparency. They have a much larger scope, and they also have notice and display and posting rules. And at the end of this presentation, there's links to these rules. I've just kinda summarized them for you here. We're gonna talk a little bit about the good faith estimate today because I think that's where there's a lot of questions.

The balance billing provision is pretty simple in my mind. It's you can't balance bill for emergency care anymore, or air ambulance and, if even if they're out of network. This good faith estimate's got some mechanics that are that are pretty complicated as we move forward.

Chapter
Legal Challenges and Controversies

There are big there are four big provisions within the no surprises act. It as I mentioned, it prohibits out of network billing for ED, the emergency room. There's this benefit reciprocity. I mentioned that as well.

For co pays, coinsurance, those types of things, any out of pocket has to match the in network rate for those emergency services, and for certain out of outpatient services as well. We'll talk through that in just a minute. And then there's no out of network billing on non ED services unless something called notice and consent is provided. And then the fourth element really is this good faith estimate.

So if you remember those four things, if you remember anything from this presentation, this slide is probably a good one. These are the big four things that the, no surprises accurately promulgates. Let's talk about some of the legal challenges that it came. It's been a pretty controversial type, piece of legislation that's came out, as we're working through it.

Enforcement. So it's really kind of a low dollar, only ten thousand. There's many hospitals out there that are frankly still balanced billing because the penalty is not that high. And if they're getting through special case agreements or other things, the money's, they're gonna do it. I think you'll see a a similar path with this as we've seen in the transparency rules, surrounding, you know, an introduction of the regulation, some monitoring, and then there'll be enforcement. I think these these, penalties will probably go up over time.

They're gonna defer enforcement. They still have.

I think people are still figuring out the compliance of this. There's been a lot of, of attention being paid to the good faith estimates. I just went out on CMS's website. They put some more guidance out there, but there isn't anyone on a sanctions list right now, for example, or a fine that I'm aware of that has been given for someone who's violated the no surprises act. There's been lots of talk about the, qualifying payment amounts and the independent dispute resolution process and making sure that the amounts that are ultimately held to the provider in terms of their reimbursement and the associated out of pocket to the patient are, you know, fair and qualified and usual customary rates, all that fun stuff. But there hasn't been a hospital that has balanced build someone and gotten fined and stayed that way. They've all been kinda unraveled and coached, for lack of a better word.

Chapter
Enforcement and Compliance Issues

CMS does have the complaint website up, that started in twenty twenty two. I always like, you know, to point this out that there is a portal available for patients. And so when a portal's available, more complaints will be coming. Make sure your organization is prepared, to respond to said results.

Texas has sued. The Texas Health Association or Medical Association sued and they won. They're saying that this is outside the scope of CMS to establish price controls on out of network bills. They feel that that's a function of a contract or lack thereof or the business that's happening between a provider and a consumer.

And they won. They said that there wasn't enough information being provided to help, stratify the differences in types of payments. CMS has actually added eight elements. I believe those are in the appendix of this deck that said, hey. If you're a sole community, if you only you're the only hospital that does transplants, you know, within a a certain radius, if you only do if you're a rehab facility, whatever, and only have certain types of of services and you're the only one, you can charge, you know, what you want and demonstrate that. And you may, in fact, have amounts that are outside of those qualifying payments.

A fifth district court actually just ruled on this, as as late as August of last year, and they said that the government has absolutely infringed on an arbitrage discretion to balance other factors along with these qualifying payment amounts as they choose. So I've been talking about QPH for a while. If you don't know what those are, basically, when there's a dispute between what the facility charged and what the government thinks the facility should charge based off of, you know, the the the rates that the payers are reimbursing and the charge masters in that area, it has to go to something called arbitration.

There's a timetable and a clock there. I I think I've got some information here, and we'll talk about this a little bit more, later. But, basically, if there's a disagreement and the payer in the hospital or the payer and the patient cannot come to an agreement on what the amount is that qualified payment amount is calculated, based off of the Metropolitan Statistical Area, the providers that are there, and that is set. And then they each give a bid, as weird as it sounds, the facility and the payer, the facility and the pay and they look at the lower one and grant that.

Chapter
Dispute Resolution Process Overview

There's been a lot of, discussion and things happening with this kind of baseball arbitration, it's called, as folks are looking at it. But that's what QPA is, is this qualifying payment amount that's based off kind of the average payments in an area. And, oftentimes, that's lower than what the hospitals would like. Texas won again.

As I mentioned in August, they've challenged this rule four times. The ruling, also vacated an increase of these administrative fees to get records.

They kept them down at fifty bucks. The judge removed barriers for providers to file, so you can actually file claims, quicker now.

If you don't agree with what the QPA was and and if you want to accelerate parts of this independent dispute resolution process where it ultimately goes to that if people just can't agree on what this amount should be.

CMS is also enforcing price transparency. It's quadrupled since two thousand. It's just important to kinda keep that hand in hand as you're looking at it. There's seventeen hospitals as of January.

This list isn't sanctions list. You don't wanna be on this list. It isn't directly related to no surprises act, but nonetheless, if you're doing well on transparency, you're probably doing okay with no surprises. So you wanna make sure that that your patients understand what their coverage is, if any.

And if they do or do not have coverage, what their out of pocket is, and mechanisms for them to pay for that that are easy and understood, discounted if they can't afford it, and certainly discounted off of your bill charges so that you don't run into out of network issues. And then charity or sliding scale payment plans are offered as well. So your financial assistance policy is very important to look at as you're looking at this, and that'll pretty much keep you out of hot water with no surprises act as long as you're not balanced billing in the ED area, and you've got a good faith estimate process that's pretty good.

There's some resources there in that QR code, that you can go to if you have questions about transparency and other things.

Enforcement of co providers and co facilities has been extended.

It's actually still extended beyond twenty twenty five. There was this enforced. There was, this argument that there was gonna be some enforcement in twenty twenty two about this, and and hospitals providers weren't quite ready, to meet the requirements. And the government said we understand.

We released the rule. We'll give you time. I went out and looked. This rule is still in place.

They haven't touched it since then. There's been some guidance that has came out, but they aren't really enforcing this rule yet. I think that's important to understand. They are providing guidance when they get a complaint to the hospitals and providers that that say you did not have a good faith estimate, or your your balance billing free out of network.

That's not possible or you're well above the qualifying payment amount and you need to, go to arbitration or or, follow the independent dispute resolution process if you feel that you should be owed more dollars, but you're well above that, those types of things.

Let's talk about this debacle that's happened with the dispute resolution. So, again, this is where the facility fundamentally disagrees with the reimbursement that they're getting. I feel it's too low, and so they go to the government to really, challenge that, as far as these on a case by case basis. Almost a half a million gang, disputes have came through. It's probably well over, you know, six hundred thousand now if I had to guess. Way more than the government thought they would get.

And, there's frankly a very large backlog. And the GAO, the general accounting office has been involved to kind of look at that and understand where they're at. And there is a high volume of disputes. This case is nearly four time fourteen, sorry, times greater than the department initially estimated.

They frankly don't have the staff to do it, and it's expending significant times of resources. So this rule is birthed. It was put out in the market, and they said, well, if you don't like how you're getting paid or the amounts, you can certainly appeal that, for lack of a better word, through the IDR. And then we'll, you know, look at it and reconsider.

Well, there's, you know, a half a million of them out there, because they've all been pretty much lower.

There was an outage. They were put on pause for a little while because it kinda broke the system. There were so many of these things.

HHS issued some new rules.

The fees, went from fifty to one fifteen per dispute. That's just because of the administrative burden. They increased the fee range to two hundred. Again, the Texas Medical Association has sued on some of these in one. The IDR entities will have discretion to increase fees for disputes just because of all the administrative burden to do them as well.

Chapter
Impact of the No Surprises Act

Key components, you know, the congressional budget office also looked at some of this, and they said that what's supposed to have happened when you put the no surprises act out there when it was voted on in congress, what they said was supposed to happen. The intention of the bill was to reduce insurer spending for out of network care.

It was supposed to increase the spending on uncovered out of network services indirectly and also reduce negotiated prices. That was supposed to have been what happened. What really happened was that the payments have actually quadrupled of Medicare.

This is and prices have gone up. And so these decisions appear closer to the amounts insurers have historically paid, and these outcomes are reflecting the providers submitting relatively high offers through their process and getting it. So kinda putting this in English, this was supposed to kinda curb high cost bills that were a surprise. And actually, those high cost bills have stayed, but now there's just more communication around them and awareness, if that makes sense. You still can't do it in the ED, but that notice consent can happen on the outpatient side, in certain care settings, and it certainly is. This is just more data, that's showing these independent dispute resolution decisions that there are, well above the prior mean in network prices there, you know, four three, four, five hundred percent higher, in a lot of cases.

And the decisions are well above Medicare rates as well as the qualified payment amount or the average rate that's there. The offers are coming in there, and the providers are winning seventy to eighty percent of the time. So if you're a provider listening to this webinar, it's very important for you to one have a pretty solid charge master process and please come see me if you don't. And then secondarily, you know, you're able to defend why your prices are higher because you win eighty two percent of the time when you go to dispute resolution.

Chapter
Best Practices for Compliance

Let's talk about some best practices for compliance. This is a really nice flowchart from the American Medical Association, and it it starts up there at the top. Are you in network or not? If you are and all your doctors are, then the contract that you have with that, carrier insurance company works and you're done.

You just go straight left to right there at the top. We wouldn't be having a webinar today if that was the case with one hundred percent of the patients that came through your doors. So there obviously are some where your facility is not in network with the patient. My hospital followed this workflow.

Then is there a single case agreement in place? That's the best practice. So anybody that comes to your hospital that's either self pay or out of network really should be executing an SCA if you can get to it, especially on high cost things. And that just basically is a contract without that in the absence of one between you and the patient instead of you and the provider or you and the the insurance company and the patient, if that makes sense.

So, basically says, hey. You're agreeing to come in. Here's what our fees are. Here's what you're gonna pay.

Sign here. Thanks. And I've got example SCAs if you need to see them. But it's not a surprise because you both signed this contract, and you know what the services there are and the patient pays.

If all the providers are also covered in that, then the SCA up controls as well. So, so, you know, if you're doing good network flagging and know what payers are or are not are not in network, and you're also doing a really good job of identifying those out of network or self pays and establishing an SCA, you're not gonna have that much noise with the with the no surprises act. And I see a lot of facilities, you know, kinda stopping there, and they do a pretty good job.

If all the providers are not in the network and you don't know that or have a good grasp on it and there's just a lot of volume and it's inconsistent, that's where you start getting into the lower stratifications of this workflow. At the very top, we'll go back up there again, are all the docs in there?

Can they consent you? Remember, this is only for things that are not emergency. You could never ever balance bill for emergency. But if they're coming to a rehab or they're getting an x-ray or a surgery and you tell the patient, hey. You're coming here and we're not in your insurance company's network. You're going to pay out of network and that shouldn't be a surprise and you sign that, then you have a workflow for consent and notice.

And then the state surprise billing laws apply. They typically read that way. You have to let a patient know through a waiver process. They sign that at admission saying anything that's not covered, that's out of network or self pay, you're responsible for, and that should be clearly outlined.

Now the rules have gotten more specific. You can't just say blanket. You gotta pay for anything that happens that your place doesn't cover. You gotta be specific for this service, this date, and we'll walk through that in a minute.

Over on the left side are all the docs provided. We talked about that. If they're not, can they get consent? Same workflow that you see over there on the upper right corner.

So really, this workflow hinges on two things. Are the doctors and the facility all in network? If they're not, you've gotta either follow an SCA or this no surprises act workflow. One of the two.

This is another really nice workflow from Panacea.

Starts with the patient on the top. I'm not gonna walk all the way through it, but it basically asks those questions in those diamonds. And it'd be really good to put a policy to this in your organization.

If you remember anything from this webinar besides the big four, remember this one. This is a really nice workflow to kinda pressure test whether or not you're compliant and you've got things in place. Are you asking these diamond questions? Are you documenting the answer? And are you having different actions that you could go back to on audit and show that you did what you said you did on here? And that way, you kinda will stay in the good graces of the regulators and stay out of fines.

Chapter
Good Faith Estimates Explained

Who gets a good faith estimate? For now, it's only required for uninsured self pay. Now the government's looking at adding these to commercial plans. We'll see what happens.

HHS defines uninsured or self pay patients as a person who does not have benefits. So where this gets weird is something that's not covered or they're using HIPAA high-tech and opting out of their insurance. So they may have and pay premiums for insurance, but it may not cover them. That makes a GFE apply, gangs. That's very important to know that piece.

CMS has a model, good faith estimates on their website. You can go out and you can just Google if you want, but GFE, CMS example, and this will come up. But my advice with this is if you're creating GFEs in your organization, it better darn well look pretty close to this. If you change it, you better say why and be able to defend it. Because on audit, the auditors are gonna wanna see this and something that looks very close to this. So I wouldn't mess with the order, the font, the shading, those types of things unless you've got a compelling reason to do so.

Things I see where folks have trouble with good faith estimates is they're not clear. They've made a form themselves.

They only they give them out an emergency. Can't do that gang.

They're only in two languages. You have to follow kind of the ethnicity rules and the preferred language rules that exist under the joint commission and those types of things. They follow that here as well.

They only cover the primary facility. They aren't looking at the extenders. So anesthesiology, pathology, radiology, all the ologies.

You wanna make sure you're there. It's static. You gave it out six weeks ago, six months ago, and you didn't update it. Maybe your charge master changed. Maybe the service changed. Maybe it changed when they got there. That that whole workflow can get really dicey, with the patient.

You never set one. It's too old. They're only supposed to be a year.

You had a price increase across the board and didn't go back. That that typically will happen on ones maybe you did yesterday or a month ago. You have a price increase today across your charge master. You gotta go back and do that.

Sending them not sending them out for zero charges. You absolutely have to send as a GFE out even if no money's owed.

Non traditional services count. Dental, therapies, chiro, those types of things. Changes in coverage. So scheduling scheduled it. There's coverage at the time. They don't have it now when the service is here.

Time to put a g f e out in place. So very important that these good faith estimates are out there.

Ten three one rule is a good rule to remember for your organization.

They need to go out ten business days in advance of the appointment.

And the GFE has to be set three days before that.

If they're not scheduled, they're a walk in. They have to go out three days from the request. So they're not required, but if someone requests one, you have seventy two hours from the date they requested it to turn it around.

If it's three to nine days in advance, you have to turn it around within a day of the request.

And, if they're not scheduled, and it's less than three days, they're not required at all. Kinda confusing here. I think we'll see some more as there's monitoring enforcement, but it's a good rule to remember this ten three one rule. Basically, ten days out, gotta get it in three days. If it's three days out, gotta get it one day. And if it's less than that, you don't have to do anything.

What if it's wrong? Well, patients could challenge bills if they're off by more than five hundred four hundred dollars. Sorry. And, they could also be subject to ten thousand bills.

Now this four hundred is really arbitrary number, and it's actually very easy to be off with an estimate by that amount. I've seen some complaints come through on these, and typically, the facility just does an adjustment. But just know that that that rule is out there. Other details with the good faced estimate is that they're really using the health and human services model posting.

The notice of this must be posted at all entry points and where people are scheduling.

You must update it if things change, either the scope of services or the prices themselves.

Recurring services can use a GFE for up to twelve months. As I mentioned, they expire. They're considered part of the medical record gang, so they absolutely should be scanned and put into that. You must provide copies to the patients and also be able to hold them for six years. That's the statute of limitation in terms of your record keeping, and we're waiting on rules on whether or not they apply to insured as I mentioned.

Notice and consent requirements. Notification is for all visits.

Notices must come in fifteen common languages and be able to believe they receive the costs and relative network coverage and talk to what they understand and all of those things. And then consent is required for non emergency balance billing. So a good faith estimate's also required, and they receive a consent to waive no surprises at protections because they're going to proceed. So this scenario's fairly common, but you've realized through those workflows I showed you that you've got a patient that's either walked in or on the schedule for a service that either the facility, the doctors involved, or both are not a network in that plan or they're self pay. You have to tell that patient, you are coming in here and you do not have benefits for this. We are going to bill you the difference.

You are agreeing to what that difference is. Here is what the difference is and we'll update you if changes to that difference come. And that, has a seven year requirement. I had six earlier.

I think seven's probably the the correct one for all of these just to be safe. But know that that's the rule, and there's a list of services CMS has on their website, but you can name one and most of them are on there. That they've been pretty, holistic with that. Let's talk convening and co provider here for just a minute.

Chapter
Understanding Convening and Co-Provider Roles

Convening is really the quarterback. They're the one that scheduled the test, or the procedure.

And they have these elements on the good faith estimate that's required.

They're all listed there. This co provider part is really hard. There's a lot of debate right now, but this is anybody else who could be involved with that service on the good faith estimate and anesthesiology, rehab, those types of folks, pathologies, all those ologies, and you're supposed to talk to them, get that information, and put it all on one form. And if you're the one that ordered the test and scheduled it, you gotta go out and hunt and gather all that. I don't see how the government's gonna enforce this, but this is what the rule says as of today. So there's been a lot of talk about whether they're gonna enforce it or not. But when you hear about convening and co provider, those are what they mean.

Effective the first of twenty twenty three, the GFE must include any item or service that is reasonably expected to be provided in conjunction by another provider facility. So like I said, the rule says, any charge that's gonna hit that patient regardless whether it comes from your facility or someone else that's associated with that visit, you gotta put it on there. Very difficult to comply with this but that's what the rule says.

Chapter
Preparing for Independent Dispute Resolutions

Preparing for your independent dispute resolutions. Make sure your folks are really good on their estimates. They understand coverage. Funny mechanisms are established in advance of care at the very latest before discharge.

They the patient, the provider, and the payer, if there is one, are all on the same page for who's paying what and how much.

A very important, that first bullet. Arbitration can be expensive, so make sure you've got a budget for fighting this stuff. You saw the seventy to eighty percent win rate, but it's not free. There are processing fees, the hundreds of dollars for each one.

And if you're doing ten or twenty of these a month, that starts to add up. And make sure you're staying up to date. It is a novel piece of legislation. It is dynamic.

I went out and looked. I hadn't seen too many changes since the last time I gave this talk. But, nonetheless, feel free to keep in touch with me too. I'll I can send updates out, or you can ask me when you when you're watching this, hey.

Has anything happened since the time you recorded it? And when we're doing it, we'll we'll certainly move forward.

Chapter
Tips for No Surprises Compliance

Pen tips for no surprises compliance. I love this slide too. It's another important one. Make sure your staff's educated. As I mentioned early in this presentation, if you're doing a good job with transparency at your organization, estimates, charity, charge master maintenance, you can back into where somebody got a price, what they owe, and why. You should be okay with most of the no surprises act stuff. This is really meant to be a safety net for when you bill or an entity bills an extraordinary amount for something that really should be billed at allowed charges or and not billed.

Host your model up there you know, update your payer directories. Make sure that you know who isn't out of network both on the hospital and professional billing side. Make sure your chargemaster is updated at least annually. I I can't tell you how many places I've seen where that's not done.

And, again, come see me if if you have questions about that. Connect with those co providers and see if they've got the same insurance contracts you have. And if they don't, identify the ones to where maybe you both can get to somewhere. If you if because that'll help eliminate ninety nine percent of the problems.

Verify each patient's insurance.

Make sure that that you're you're doing that every time, they come in and and we had a thirty day, you know, pre reg from history rule at my hospital and that's a fair rule. But after thirty days, you gotta recheck again, gang.

Use in network benefits for out of network patients. So making sure you're following that and that'll keep you out of trouble. Make sure that notes and consent is in place. Provide good faith estimates consistently and compliantly and make sure you're looking at them.

You might wanna do a GFE audit at your organization and, you know, how many GFEs did we send out? If that number is zero, that's a problem. We should have some. And if they went out, were they correct?

Would they have changed those types of things? Make sure you've got disclosure of those patient rights and really embrace this stuff as you move forward.

Chapter
Patient Rights and Consent

Some other considerations, maintain a record of in and out of network statuses for the facilities so people know. When estimates are created, the hospital must be able to notify the patient if it's out of network and obtain a record of consent for certain procedures as I mentioned. Facility or provider must submit a copy of that to the payer as well under the AOB provisions. That's kind of an interesting rule.

A lot of are not doing that because there's no enforcement yet, or they say the claim is satisfying that rule. Just something interesting that's in the law. If a patient protected under the no surprises act, the hospital may collect the cost sharing amount, co pays up to the patient's in network benefit. They can't collect the out of network benefit if they're not noticed and consented or if they're in an ED setting, if that makes sense.

When the hospital submits a claim that is covered, this must be noted on the claim as well. She should be able to tell the difference between claims that fall under NSA protections and ones that do not. Payers will calculate the qualifying payment amount when that when that's in place and provide notification to the hospital of the disagreement that goes to that IDR process we talked about. Defend your charge subscription master and your unique role as well.

Chapter
Financial Clearance and Patient Communication

Other considerations for the no surprises act. Ensure your RCM is solid. If you're not managing your claim and collection cycle in a good way today, no surprises act is like gasoline on the fire. It's gonna make it worse.

So ensure your financial clearance. Every patient, every time. You know, the funding mechanism that's gonna be there, how much they're gonna owe roughly, how much the payer's gonna pay if there is one, and the patient knows what those amounts are and whether or not it's in network.

Add as little to the process to be in compliance to. I wouldn't, you know, boil an ocean with this stuff. Work with your payers. I know that sounds hard, but ask the payers what they're thinking about the AEOB.

Find out which ones are out of network and talk to them about cases that are to come up and the best way to handle. If you've got good relationships there, those two cans of string, that'll help out. Look for those hot spots. Make sure your provider directories are up to date. Of the docs that you have credentialing at your facility, the ones that are allowed to practice there for your medical staff, what does their insurance network matrix look like? And does that match the hospitals and where are their mismatches? Review all your contracts.

Chapter
Understanding State and Federal Law Interactions

Arbitration's probably in there. Out of network provisions are probably in there as well. Make sure that those mechanisms are there because remember, state law and contract law trump the federal law right now. They actually supersede it.

So it's very important to look at that and understand where you're at. And then if they're in the absence of those things, then you'll have the rep the, the, federal law come into place. And then over communicate this stuff. Hey.

Do you have questions about the no surprises act? Here's a flyer on the no surprises act. We wanna make sure you're not being balanced bill for services that are out of network. Here's what that means.

Make sure you have that information. But a happy and informed patient is a lot less likely to complain and just work directly with you, and you can fix it right there instead of having the government fix it for you. Ton of resources right here. I knew I threw a lot of information at you.

A lot of these come from sent CMS. There's some from HFMA there as well. Go click on them. That's note that first one is updated literally almost every week with new information as you look.

Chapter
Model Documents and Compliance Guidelines

And then there's model documents out there, as I mentioned, that talk about what the no surprises act is, how to be compliant, who it applies to, what type of facilities, what GFEs are required or not, the timing, all those things I kinda covered at a high level with you. They have the balance billing notice and consent form as well. So for those services where you know that they're out of network and they're gonna have a higher out of pocket, you gotta give them one of these or they can only be responsible for the in network benefit portion and you've gotta write off the rest as a provider.

So the form is here for you to use for that. And then if there's any questions, I know this might be remote or you're watching it and I'm not in the room, feel free to get a hold of me. My information's right here. It's two i's and a k.

Jonathan Wiik FinThrive.com My cell phone number is there as well.

But, watch those two i's and a k, and you're welcome to email me and say, hey. I saw your webinar and no surprises act, and, I don't agree with this or I need to see that. Or do you have any information there? More than happy to be a resource for you.

Chapter
Appendix: Key Questions and Regulations

And there's things at FinThrive that we can do for you too. That QR code also gets you to me if you need to. In the appendix, there's a ton of information on CMS in terms of some questions that they ask. I'll just flip through them quickly, but they ask about whether a GFE is required, what types of insurance, whether they're uninsured, what if you don't know what all the things you're gonna charge, what items should be on it, what things you should do when you provide the estimate, what part of the rule under the code of federal regulations is applicable, what section is applicable, where you should what how you should be giving it, all those types of things, how the IDR works, how the self pay dispute resolution works, that four hundred dollars I talked about, how the provider resolution works, how the balance billing needs to be limited for out of network per statute, what that looks like in terms of what things can go to the patient or not, how people can understand, what those bills look like and where you can and cannot balance bill, where consent is required, where g f e's are required, how you participate in the I d r, what that looks like, all of those bullets, and all of those other things.

Chapter
Conclusion and Closing Remarks

That is everything I had today.

It was my pleasure to talk to you. And again, this is Jonathan Wiik, Vice President of Health Insights at FinThrive, and I hope you enjoyed the Webex. Have a great day.

Thank you.