With the No Surprises Act taking effect in less than four months, it is critical that hospitals and providers leverage technology to ensure patients are informed about their expected care costs prior to receiving services. Despite industry improvements in the last several years, there remains a pressing need for more meaningful price transparency in healthcare. The No Surprises Act, in addition to recent revisions to existing Centers for Medicare and Medicaid Services (CMS) price transparency regulations1 and a policy push by President Biden,2 aims to continue the trend toward more patient-centric healthcare that makes it easier for patients to navigate the inherent complexity.
On July 1, the Department of Health & Human Services released the first of three regulations that clarify key portions of the No Surprises Act. In the past, many patients have received unanticipated bills for emergency services or from out-of-network providers who provided services at the patient’s in-network hospital. The No Surprises Act prohibits healthcare facilities and providers who are outside of a patient’s insurance network from “balance billing” except under certain circumstances. For example, under the new requirements, an out-of-network anesthesiologist who participates in a surgery or an emergency department physician who cares for a patient may no longer balance bill when these activities occurred at a patient’s in-network hospital. Unless the patient receives notice and provides written consent,3 providers may generally only collect cost-sharing amounts that would have been charged had the patient been in-network. This notice and consent process also requires out-of-network hospitals and providers to furnish “good faith estimates” to patients of their expected charges.4
While there are many outstanding questions5 on the No Surprises Act which will need clarification in future regulations, hospitals and providers should not wait to engage key stakeholders to ensure their technology and workflows can accommodate the dynamic nature of price transparency. In addition, while there are provisions for providing notice and consent for balance billing, the notice and consent approach cannot be used in many situations, such as for most emergency services, for defined “ancillary services” and when there are no in-network providers available.6 Here are several overarching principles for proactively providing patients with the information they need to make decisions on their care as well as striving to avoid the situations that can lead to surprise medical bills.
The push for greater transparency in our healthcare system is here to stay. Moreover, staying ahead of price transparency is not only beneficial for meeting consumer and patient expectations but is also a critical factor in ensuring organizations are compliant with the rapidly changing regulatory landscape. Taking a proactive approach and leaning into meeting consumers where they are will distinguish organizations from their competitors and result in higher patient satisfaction and ultimately stronger financial performance.
You can learn more about CMS’s Price Transparency requirements and how they impact facilities from Ogi’s interview with Chief Healthcare Executive here.
1. FY 2022 Outpatient Prospective Payment System Proposed Rule, Section XIX, available at https://public-inspection.federalregister.gov/2021-15496.pdf.
2. See Executive Order on Promoting Competition in the American Economy, July 9, 2021, available at: https://www.whitehouse.gov/briefing-room/presidential-actions/2021/07/09/executive-order-on-promoting-competition-in-the-american-economy/.
3. The notice and consent process does not apply to a variety of different scenarios, including for emergency services as well as certain “ancillary services” (e.g., anesthesia and radiology). See 86 FR 36872 at 36982.
4. 86 FR 36872 at 36983.
5. Outstanding questions include how the No Surprises Act will change current practices in states with existing balance billing protections as well as what constitutes “good faith estimates” for the purposes of notice and consent.
6. 86 FR 36872 at 36982.
7. 45 CFR § 180.60(a)(2) (“Requirements for displaying shoppable services in a consumer-friendly manner”).
8. 86 FR 36872 at 36982.
Disclaimer: The information in this article is current as of July 26, 2021, and does not constitute medical or legal advice.
Ogi Kwon is the Manager, Advisory & Assurance – Regulatory in R1 RCM's regulatory division.