|
Getting your Trinity Audio player ready...
|
Key Takeaways
-
- Out-Of-Network Providers Are Still Subject to Federal Billing Requirements
Even without insurance contracts, practices must comply with key No Surprises Act obligations, including patient cost transparency rules.
- Good Faith Estimates Are Required for Eligible Patients Before Services Are Rendered
Providers must give uninsured and self-pay patients advance written estimates that reflect expected costs for scheduled care.
- Operational Workflows Must Support Compliance Requirements
Key Compliance Duties for Out-of-Network Healthcare Practices
The No Surprises Act seeks to protect patients from receiving surprise medical bills for certain types of out-of-network or uninsured care.
The requirements under the No Surprises Act are complicated and can vary greatly depending on your practice, your services, and the patient you’re treating. Providers who run out-of-network practices often assume that federal laws like this don’t apply to them—after all, they often chose not to accept insurance because they wanted to avoid the time, energy, risk, and hassle of dealing with insurance and its complex regulations. If this sounds like you, be warned: the No Surprises Act is for you.
See our related video on the No Surprises Act.
Good Faith Estimates for Cash-Pay Patients
Since the No Surprises Act launched in 2022, compliance has been a hot topic for private practice owners treating self-pay or uninsured patients. For many cash-based or self-pay providers, the Act requires issuing a Good Faith Estimate to inform patients upfront about anticipated charges.Â
A Good Faith Estimate functions like a pre-receipt, detailing the expected costs for scheduled services. However, just providing patients with pricing isn’t enough. A Good Faith Estimate must include all services that are reasonably expected to be provided at a patient’s scheduled appointment, along with provider contact information, identification information, and required disclaimers.
For providers who exclusively serve cash-pay patients, providing Good Faith Estimates has become a routine method for enhancing transparency and helping set realistic patient expectations. Good Faith Estimates not only clarify the costs of services but also reinforce the patients’ responsibility to cover 100% of the expenses.
Special Requirements for Mixed In- and Out-of-Network Practices
For practices that include a mix of both in and out-of-network providers, though, understanding the obligations to patients becomes trickier. If a patient is using insurance accepted by the practice, and the practice is billing that in-network insurance for all of the patient’s services, no good faith estimate is required.Â
However, if an in-network provider also has out-of-network providers at the practice or refers a patient to an out-of-network provider, additional requirements may be imposed.
For example, you may need to provide a notice and consent form—often called a “Surprise Billing Protection Form”—for out-of-network providers working within otherwise in-network facilities. Specifically, an out-of-network provider delivering non-emergency services at an in-network facility must meet the notice and consent requirements established by the Centers for Medicare and Medicaid Services (CMS). CMS has released standardized forms for this purpose. In short, if a practice generally accepts a patient’s insurance but the patient will see an out-of-network provider as part of their services, the practice must inform the patient and obtain consent to that arrangement.
Ultimately, if the patient receives services from an out-of-network provider, the patient may be financially responsible for all or a portion of the fees. Ensuring patients know their responsibility before receiving those services isn’t just a good business practice—federal law requires it.
Get Legal Support.
Understanding how the No Surprises Act applies to your practice can feel overwhelming. What forms do you need to provide? Can you create them yourself? When should you give them to patients? Which patients need them? Talking to a healthcare attorney can help clarify which requirements apply to your practice so that you can meet the standards.
Many clients have sought our guidance on implementing the No Surprises Act within their unique specialty or patient population. If you’re in a state where we have licensed attorneys and need assistance with the Act’s requirements, schedule a consultation to see how our attorneys can support you.
This blog is made for educational purposes and is not intended to be specific legal advice to any particular person. It does not create an attorney-client relationship between our firm and the reader. It should not be used as a substitute for competent legal advice from a licensed attorney in your jurisdiction.
Free Attorney Consultation
Frequently Asked Questions About the No Surprises Act
Does the No Surprises Act apply to out-of-network providers?
Yes. Out-of-network providers are still subject to certain provisions of the No Surprises Act, particularly those related to Good Faith Estimates and patient billing transparency.
What is a Good Faith Estimate for out-of-network care?
A Good Faith Estimate is a written estimate of expected charges provided to uninsured or self-pay patients before services are rendered, outlining anticipated costs for care.
Are out-of-network providers required to give cost estimates?
Yes. In many cases, providers must provide Good Faith Estimates in advance of scheduled services for eligible patients, even if the provider does not participate with insurance networks.
What happens if actual charges exceed the estimate?
Patients may be able to initiate a federal dispute resolution process if final charges are significantly higher than the Good Faith Estimate.
What are the risks of non-compliance with the No Surprises Act?
Non-compliance can lead to regulatory scrutiny, patient disputes, and potential enforcement actions related to federal billing and transparency requirements.
