No Surprises Act Takes Effect – How It Applies to You

Editor's Note: The following excerpt is a preview of billing expert Sam Collins' upcoming column (scheduled for the April issue).

The newly enacted "No Surprises Act" is designed to prevent patients from getting large medical and hospital bills as a "surprise" when they assume the provider is in-network and later turns out to be out of network. It also protects patients by stipulating that they must be made aware of the costs for services and the out-of-pocket estimate that will be due.

While this law is intended primarily for large medical costs, it does affect acupuncture practices. For acupuncture providers who see self-pay and uninsured patients, as well as patients who have insurance, the rule will apply. This means patients should always be made aware of their out-of-pocket costs before you provide any care.

Standard financial agreements used in acupuncture offices likely already include some language that will aid in compliance with this part of the new rule. A typical financial agreement often will have language such as:

Many insurance policies do cover acupuncture care, but this office makes no representation that yours does. Insurance policies may vary greatly in terms of deductible and percentage of coverage for acupuncture care. Because of the variance from one insurance policy to another, we require that you, the patient, be personally responsible for the payment of your deductibles, as well as any unpaid balances in this office.

The above statement places a patient on notice that they are liable for any amounts not paid by their insurance plan. But this alone is not enough to satisfy what the new rule requires. There is also a need now to include a "good-faith estimate" for out-of-pocket or non-covered fees.

For in-network services, this would not be complicated, as these plans have a set co-pay or coinsurance amount that is easily identified in the patient's plan and should be part of your financial agreement.

For example, if a provider is part of American Specialty Health (ASH), the patient will have a specific co-pay per visit that is $10-25, and that would be disclosed to the patient. However, even ASH has exclusions for some services such as massage or manual therapy. These services may be billed to the patient, but not without prior notice to the patient that those services are excluded and are payable only by the patient. However, ASH uses a "billing acknowledgment form" so the patient is made aware of the costs beforehand; thus no surprise bills.

Always ensure that if it is not a covered service or payable by insurance, the patient is made aware of their costs of the service, as it will be completely out of pocket with no reimbursement by the insurance company.

However, out-of-network providers will need very clear disclosure that they are out of network with the patient's plan and the costs of each service. While the plan may make some payment, there is no guarantee by the provider and the patient should be notified of the cost of each service and their potential liability or estimate thereof.

Keep in mind there is no guarantee that the patients' insurance will pay and therefore the patient could be liable for the entire billed amount. An estimate can be made, but still is no guarantee based on deductibles and policy provisions of which you were not made aware.

Part of the new law does emphasize that insurance companies must be more transparent as to the amount they would allow; as well as give providers information on their allowed rates. For example, Blue Cross Blue Shield of Illinois is making its fee schedule accessible through its Availity portal. There should be additional carriers implementing this type of accessibility, as a provider of services cannot provide information to which they do not have access.

Note that it is also reasonable to ascertain allowed rates by way of past payments from others within the same plan. But keep it simple; it is what the patient will likely owe. When a provider is willing to bill for a service, they must also collect for such and not be afraid to make the patient aware of the cost.

In a scenario in which the deductible is not met, the patient may owe the full amount billed or allowed. If you are willing to bill $300 a visit, you must disclose it to the patient and make the patient aware of the amount for which they can be liable.

Editor's Note: Sam's April column includes significantly more information on elements of the No Surprises Act as they relate to your acupuncture practice and how you interact with patients regarding fees.