As a therapy clinic owner, navigating the ever changing rules and regulations of CMS can be daunting. In this article, we hope to make at least one new rule, the No Surprises Act, less confusing for you so that you can focus on running your therapy practice in confidence.
What is the No Surprises Act?
Ironically called the No Surprises Act, these rulings were one of the biggest surprises to therapists and assistants in 2021. In July 2021, “The Requirements Related to Surprise Billing Part 1” and then on September 30,2021, the “Requirements Related to Surprise Billing: Part II” was released by the Department of Health and Human Services (HHS), the Department of Labor, and the Department of the Treasury (collectively, the Departments), along with the Office of Personnel Management (OPM) (CMS, https://www.cms.gov/nosurprises).
Part I was created to “restrict surprise billing for patients in job-based and individual health plans who get emergency care, non-emergency care from out-of-network providers at in-network facilities, and air ambulance services from out-of-network providers.” according to CMS. Here is an example, you suddenly fall and have serious injuries that need immediate surgery and attention. You have no idea how much the costs of these medical bills will be. The idea behind this issue is to help people know what they will be charged earlier.
Part II provided additional rules and protections that were even more specific to prevent surprise medical billing, including: creating a dispute resolution process to determine out of network payment amounts, requirement for good faith estimates of medical services and items, and a way to appeal certain decisions.
On November 17, 2021, a third rule was issued, called the “Prescription Drug and Health Care Spending” rule which implements new requirements for group health plans and issuers to submit certain information about prescription drug and health care spending.
It is important to note that you have until January 1, 2022 to comply with these new rulings, so if you are reading this, it is important to try your best to digest and take action to stay in compliance for 2022.
And it is also important to note that, according to CMS’s High level Overview of No Surprises Act, provider requirements do NOT apply to federal programs such as Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care, or TRICARE as these programs have other protections against high medical bills.
What do you need to know as a therapy clinic owner?
There are a lot of important points to review, and so I strongly encourage you to review this helpful guide CMS created: https://www.cms.gov/files/document/high-level-overview-provider-requirements.pdf). The No Surprises Act has criteria for air ambulances and emergency medicine and these have been removed from the list below and only the point’s most pertinent to a physical, occupational or speech therapy owner are below:
- No balance billing for out-of-network emergency services (PHSA 2799B-2; 45 CFR 149.420):
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- Cannot bill those who received emergency services at a hospital or an independent freestanding emergency department for a payment amount greater than the in-network cost-sharing requirement for such services
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- No balance billing for non-emergency services by nonparticipating providers at certain participating health care facilities:
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- Cannot bill those who received covered non-emergency services with respect to a visit at a participating health care facility by a nonparticipating provider for a payment amount greater than the in network cost-sharing requirement for such services, unless notice and consent requirements are met.
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- Disclose patient protections against balance billing (PHSA 2799B-3; 45 CFR 149.430)
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- A provider or facility must disclose balance billing protections and how to report violations.
- Providers or facilities must post this on their website, within their location (if they have one) and provide it in a timely fashion to their patients.
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- Provide a good faith estimate of the expected charges in advance of scheduled services, or upon request, to uninsured (or self-pay) individuals:
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- The good faith estimate must include expected charges for the items or services that are reasonably expected to be provided in conjunction with the primary item or service, including items or services that may be provided by other providers and facilities.
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- Ensure continuity of care when a provider’s network status changes (PHSA 2799B-8)
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- A health care provider or facility must inquire if an individual is enrolled in a group health plan, group or individual health insurance coverage offered by a health insurance issuer, a Federal health care program or a Federal
- The provider or facility must provide notification (in clear and understandable language) of the good faith estimate of the expected charges, expected service, and diagnostic codes of scheduled services.
I hope this article has helped you understand this new policy and how to implement it. Below are some helpful resources that we, at HelloNote, recommend you read to further understand the impact this has on your practice. The resources below as well as from CMS’s webpage, https://www.cms.gov/nosurprises, were used to summarize this article.
- Federal Independent Dispute Resolution (IDR) guidance for certified IDR entities (Download Guidance) (PDF)
- Guidance on good faith estimates and the Patient-Provider Dispute Resolution (PPDR) process for people without insurance or who plan to pay for the costs themselves (Download Guidance) (PDF)
- Standard notice & consent forms for nonparticipating providers & emergency facilities regarding consumer consent on balance billing protections (Download Surprise Billing Protection Form) (PDF)
- Overview of Public Health Service (PHS) Act Provider and Facility Requirements: https://www.cms.gov/files/document/high-level-overview-provider-requirements.pdf