Confused or Frustrated by No Surprises Act Compliance? AccuReg Has You Covered
Providers across the country are struggling with patient care, acute labor shortages and rampant clinician burnout, and unfortunately, now you can add drowning in government regulations to the already long list of industry challenges.
The regulatory compliance burden has never been higher, according to the Medical Group Management Association’s Annual Regulatory Burden Report, which surveyed more than 500 physician group practices in which 89% of respondents said their burden had increased.
One of the chief culprits: The No Surprises Act (NSA), which is hitting revenue cycle teams especially hard. To prevent surprise bills, the NSA requires providers to provide good faith estimates to uninsured or self-pay patients in advance of service and out of network disclosures to make patients aware that some of their care by out of network providers may be subject to balance billing. In the survey, NSA ranked second only to prior authorization, with more than 70% of respondents calling it “very or extremely burdensome.” If you run a revenue cycle department, you know much of this burden is falling largely on already overwhelmed teams.
What the NSA requires you to do
NSA regulations cover communications with patients by both providers and health plans. The regulations are intended to protect consumers from surprise medical bills by requiring private health plans to cover emergency services, regardless of site or physician, on an in-network basis. They also prohibit physicians, hospitals or other providers from billing patients more than in-network cost sharing for certain other services, unless providers obtain their consent prior to receiving care.
At AccuReg, we released several updates during 2022 to help automate the new processes of patient notification that providers must adopt to achieve compliance and avoid possible fines of $10,000 per violation.
Additional Help is Available
AccuReg has been auditing patient and insurance data and alerting registration staff to thousands of types of compliance and payment risks for 18 years.
No provider wants to send patients a bill they did not expect. Providers are working hard to comply, but it’s complex and billers depend on automated early detection, alerting, price estimation and authorization systems. Here are three ways AccuReg helps customers ensure compliance with various mandates in the Act.
1. Out of network cost-sharing for emergency services
Current Challenge: This requirement compels health plans offering any emergency benefits to cover benefits for members at any provider without need for prior authorization, regardless of whether they are a “participating provider.” They also must provide these services in a manner that is no more restrictive than the requirements for emergency services received from participating providers and cannot require greater member cost-sharing than is required from a participating provider.
Solution: For customers using Payment Estimation, staff can manually create an estimate including facility and employed physician fees using cost sharing elements associated with in-network benefits, regardless of the payer. Out-of-network disclaimers and dispute process, as well as state specific balance billing disclaimers, can be included with their estimate.
In addition, you must post information at your facility’s physical location informing patients of their protections under the NSA.
2. Out-of-Network notification and consent for non-emergency services
Current Challenge: The Department of Health and Human Services developed standard notice and consent forms for use when providing services to covered individuals with group or individual health insurance. These documents must be provided to patients by a nonparticipating provider when furnishing certain post-stabilization or emergency services.
Solution: Using our Eligibility Verification tool, AccuReg customers can utilize edits that notify revenue cycle employees if an employed provider is out of network by plan code or if the payer is unable to determine provider status. Furthermore, customers using Payment Estimation can create an accurate estimate that includes notice and consent forms in case the patient receives non-emergency services post-stabilization. We can also hard code physicians who are known by the facility to be out of network for a certain plan code, allowing customers to flag services that may be provided by an out-of-network clinician and auto-generate notice and consent forms.
3. Good faith estimates for uninsured (self-pay) patients
Current Challenge: Since Jan. 1, 2022, providers must provide an uninsured or self-pay patient a good faith estimate of expected charges after non-emergency services are scheduled, or upon request. Providers must share this estimate within one business day after scheduling and no later than three business days after scheduling. Providers must also include an itemized list of each item or service, grouped by each provider or facility offering care, so that each item or service contains the expected charge.
Solution: For customers using Payment Estimation, AccuReg can help facilitate the creation of a GFE estimate for self-pay patients. If an estimate is not able to be generated due to missing CPT code information, AccuReg will alert staff to obtain required information.
Create a Winning Strategy with AccuReg
NSA is complex and compliance is not easy—but when you have the right patient access technology in place that detects, alerts, and communicates to the provider and the patient, and the right people and processes in place, your hospital can overcome requirement obstacles to avoid fines and satisfy patients. Watch the Becker’s on-demand webinar, “The No Surprises Act: Creating a Winning Strategy,” to learn more.