Editor' Note: The following is excerpted from Sam Collins' upcoming Ask the Billing Expert column. Look for even more details on the No Surprises Act in the April 2022 issue.
The "No Surprises Act" is designed to prevent patients from getting large medical and hospital bills as a "surprise" when they assumed the provider was in-network and later turned out to be out of network.
While this law is intended in particular for large medical costs, it does affect chiropractic practices. For chiropractors who see self-pay, uninsured patients, as well as patients who have insurance, the rule will apply. This means patients should be made aware of their out-of-pocket costs before receiving the care.
The Good-Faith Estimate
However, the above alone is not enough to satisfy what the new rule requires. There is a need now to include a "good-faith estimate" for out-of-pocket or non-covered fees. For example, a Medicare patient is made aware that services outside of spinal manipulation are not covered by Medicare and those services are 100 percent liable by the patient. Those services and costs are then made known to the patient so they understand their financial liability. This law essentially requires the same for all patients for any out-of-pocket fees, whether cash or insurance both in and out of network.
In vs. Out of Network
For in-network services, this would not be complicated, as these plans have a set copay 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 copay 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 from the patient.
However, ASH uses a "billing acknowledgment form" so the patient is made aware of the costs prior and essentially no surprise. Think along the lines of the use of an advance beneficiary notice (ABN) with a Medicare patient.
On the other hand, 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 that there is no guarantee that the patient's insurance will pay the full amount; therefore, the patient could be liable for the entire billed amount.
Insurer Requirements That Will Benefit You and Your Patients
Allowed Rates: Part of the law also emphasizes 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 the Availity portal. There should be more carriers implementing as a provider of services who cannot provide the information they do not have access to. Note that it is reasonable also to ascertain allowed rates from past payments from others within the same plan.
Provider List Updates: The law also requires insurance carriers to keep their list of providers up to date so patients who choose a provider based on their list are not later liable for amounts when the provider was out of network. The insurance plans have a duty to verify who are or are not "in-network," and must do so every 90 days. Their provider directories must be updated within two business days when a provider updates their information; the same for providers who no longer participate.
This is to provide patients a clear list of providers who are in-network at any facility and not get a surprise of a provider in an "in-network" facility who is out of network. This means an office with multiple providers who do not participate in all the plans must be clear to their patients as to which plans' providers are or are not part of. If the provider fails to provide this information, the patient would not be liable for that "surprise bill" from an out-of-network provider.
Payment / Denial Notices: An initial payment or notice of denial is required from health plans to the provider within 30 days of submitting a bill. The law also creates stipulations that protect providers from erroneous timelines to submit claims.
Dispute Issues: There is also a dispute resolution that may be used by the patient to dispute a bill or the provider who may dispute fee allowance by the insurance payer. While this does place onus on a provider to disclose fees and costs of services, insurance payers must provide transparency of their allowance or payment as well.
Yes, it does apply to a chiropractic office, but the law is to protect the consumer, and as the provider is, in essence, a consumer of the insurance system, it should increase a provider's ability to have clear allowed rates and payments so they may provide patients accurate out-of-pocket costs.