Surprise Medical Billing Act

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Surprise medical billing, also known as balance billing, has become a growing problem for patients in the United States. It can occur in both emergency and non-emergency situations, often resulting from patients receiving care from out-of-network providers or facilities without their knowledge. Surprise medical bills can be for large amounts, may not count towards a patient’s deductible or out-of-pocket maximum, and can lead to medical debt. This can deter insured individuals from seeking needed medical care, reducing access to care. To address this issue, the No Surprises Act was enacted as part of the Consolidated Appropriations Act 2021 (CAA-21), which provides federal protections against certain types of surprise medical billing.

In this webinar, attorney Eric Boughman addresses the fundamentals of the No Surprises Act, part of the Consolidated Appropriations Act 2021 (CAA-21), which has implemented interim final regulations (IFRs) that outline the requirements for providers, as well as facilities, to comply with the prohibitions on surprise medical bills and balance billing. These requirements include processes such as notice and consent exceptions, provider disclosures, good faith estimates, provider directory information, the Independent Dispute Resolution (IDR) process, and enforcement with penalties.

We will also talk about The No Surprises Act. It is aimed at protecting patients with private health insurance from unexpected medical bills and limiting excessive cost-sharing for out-of-network services. It applies to private payors, providers, and facilities, and prohibits balance billing for emergency and non-emergency services, as well as air ambulance services provided by nonparticipating providers. The Act also requires providers and facilities to disclose information to patients, comply with notice and consent requirements, provide good faith estimates of charges, ensure continuity of care during network changes, and improve provider directories.

In discussing the prohibition on balance billing, we’ll talk over the protections against surprise billing in the No Surprises Act and IFRs apply to emergency care, certain non-emergency care, and air ambulance services if the patient cannot choose a participating provider.

Eric will also talk about good faith estimates. The No Surprises Act introduces a requirement for providers and facilities to provide good faith estimates of charges for scheduled items and services, or upon patient request, at least three days in advance. This estimate should reflect the anticipated amount the provider or facility expects to charge, even if they intend to bill the health plan directly.

From a continuity of care perspective, we will discuss how providers and facilities are required to ensure continuity of care for patients who are undergoing treatment for serious or complex conditions, institutional or inpatient care, nonelective surgery, pregnancy-related care, or terminal illness.

We will also discuss the requirement imposed by the No Surprises Act on providers and facilities, to provide accurate provider directory information to health plans, including individual providers’ contact information and facility details when entering or terminating a network agreement, during material changes, or upon request.

Finally, we will discuss the consumer complaint process. Individuals or their authorized representatives can file complaints with the Department of Health and Human Services (HHS) regarding violations of balance billing requirements, and HHS will process complaints by reviewing the information and making determinations.

Learning Objective:

• Knowing the No Surprises Act.
• Identifying key terms and definitions.
• Understanding the prohibition on balance billing.
• Knowing good faith estimates.
• Understanding continuity of care.
• Identifying provider directories.
• Understanding the complaint process.

Areas Covered in the Session:

• Introduction to Surprise Medical Billing Act
• No Surprises Act
• Definitions of Key Terms
• Prohibition on Balance Billing
  • Emergency Services
  • Non-Emergency Services
  • Air Ambulance Services
  • Disclosure Requirements
  • Determination of Out-of-Network Rates
  • Initial Payments to Providers and Facilities
  • Total Payments
  • Independent Dispute Resolution Process
  • Notice and Consent Exception
• Good Faith Estimates
  • Patient-Provider Dispute Resolution Process
• Continuity of Care
• Provider Directories
• Consumer Complaint Process
  • Enforcement of Provider and Facility Requirements
  • Interaction with Existing State Laws
  • Preemption
  • What Providers and Facilities Should Consider
  • Clinical laboratories
  • Behavioral health crisis facilities
  • Future Rulemaking
  • Implementing Requirements
  • Providers and facilities need to create cross-functional implementation teams, including:
    • Legal
    • Compliance
    • Billing
    • Finance
    • Operations
    • Provider Network
    • Information Technology
  • Legal Challenges

Suggested Attendees:

• Legal counsel and other professional advisors to healthcare providers
• Healthcare providers and staff
• Hospital and healthcare facility administration
• Vendors and contractors who work in the healthcare sector
• Physician
• Nurses
• Physician Assistants
• Healthcare Billing and Coding Staff
• Credentialing and Enrollment Specialists
• Healthcare Administrative Personnel
• Clinic Managers
• Credentialing and Enrollment Specialists
• Healthcare Administrative Personnel
• Practice Managers
• Auditors
• Compliance Officers
• Medical record supervisors
• Health Information Management Administrators and Technicians
• Other Personnel Interested in Billing Privileges with the Medicare Program

Presenter Biography:

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