ThenosurprisesAct (NSA)

WHO: Where it Applies

- All out-of-network emergency facility and professional services

- Post-stabilization care at out-of-network facilities until such time that a patient can be safely transferred to a different facility

- Air ambulance transports

- Out-of-network services delivered at or ordered from an in-network facility

WHY: What is the Purpose

- Create Consumer Cost-Sharing: Holds consumers harmless by limiting their costs to in-network costs, including deductibles and out-of-pocket maximums

- Address Logical Care Settings:Emergency and post-stabilization care and non-emergency care in in-network facilities, fully insured and self-funded plans. Includes air ambulance services, but not ground ambulance services

- Establish a Path for Dispute Resolution:An independent dispute resolution process will trigger if parties do not reach a voluntary agreement in a 30-day negotiation period

- Set Enforcement at a State Level with Federal Backup: States have primary enforcement role. Federal enforcement will step in when states that lack authority or fail to substantially enforce the law. Federal enforcement uses civil monetary penalties

HOW: What Steps Should be Taken

- Understand how the law applies in the states where the provider or facility renders services

- Identify, benchmark, and compare current payment trends for out-of-network claims.

- Fully understand the Dispute Resolution Process to determine when to initiate a dispute

- Audit previous claims to determine if balance billing occurred when prohibited

- Stay up to date on changes through participation in the PARA NSA Q&A bi-monthly webinars

Quest ion: We have t he Disclosure Not ice post ed in our regist rat ion area and w ebsit e. Are w e are also required t o hand out t he Disclosure t o each insured pat ient for every visit ?

Answ er: Providers and facilities must issue the Disclosure Notice in-person, by mail, or by email, as selected by the individual.

This is an excerpt from the instructions on the Model Disclosure Notice:

Who should get this notice

In general, providers and facilities must give the disclosure notice to individuals who are:

- Participants, beneficiaries, or enrollees of a group health plan or group or individual health insurance coverage offered by a health insurance issuer, including covered individuals in a health benefits plan under the Federal Employees Health Benefits Program, and

- To whom the provider or facility furnishes items or services, but only if such items or services are furnished at a health care facility, or in connection with a visit at a health care facility.

Providers and facilities shouldn? t give these documents to an individual who has Medicare, Medicaid, or any form of coverage other than previously described, or to an individual who is uninsured

Providing this notice

Providers and facilities must provide the notice in-person, by mail, or by email, as selected by the individual The disclosure notice must be limited to one, double-sided page and must use a 12-point font size or larger.Providers and facilities must issue the disclosure notice no later than the date and time they request payment from the individual (including requests for co-payment or coinsurance made at the time of a visit to the provider or facility) If the provider or facility doesn? t request payment from the individual, they must provide the notice no later than the date they submit a claim for payment to the plan or issuer

Quest ion: We have an anest hesiology group t hat t reat s pain pat ient s in our facilit y We bill t he facilit y based charges and t he Anest hesiology Group bills t heir pro fee charges. They are in cont ract w it h very few payers. As a result of t he NSA and t he inabilit y t o balance bill out of net w ork pat ient s, t hey are proposing t reat ing all of t heir out of net w ork pat ient s as self pays Our facilit y is in net w ork w it h m any payers and t herefore obliged t o accept in net w ork insurance for t hese pat ient s

If facilit y is in-net w ork and ancillary group is out of net w ork, w hat is t he facilit y responsibilit y t o inform pat ient of self pay st at us proposed by ancillary group?

Answ er: The No Surprises Act was written with the intent to protect patients from balance bills; one of which is from out-of-network providers within an in-network facility The actions of the anesthesia group are an attempt to circumvent the law We can? t answer either one of the questions because the actions of the anesthesia group is not compliant and needs to be directed to your legal counsel

CMShas published a document which outlines the NSA and clearly states that ancillary services are prohibited from billing the patients who schedule services at an in-network facility for anything other than their co-pays and deductibles. Attached that document and provided an excerpt which may assist you in explaining to the anesthesia group that they need to submit a claim then negotiate reimbursement with the health plan.

High level overview of No Surprises Act provider requirements (cms.gov)

No balance billing for non-em ergency services by nonpart icipat ing providers at cert ain part icipat ing healt h care facilit ies

Non-participating providers of non-emergency services at a participating health care facility:

- Cannot bill or hold liable beneficiaries, enrollees or participants in group health plans or group or individual health insurance coverage 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

Quest ion: We have received a not ice from an out -of-net w ork insurance st at ing t hat under t he No Surprise Act w e are unable t o balance bill a pat ient due t o t he pat ient being seen in an em ergent set t ing. We w ant t o disput e t his claim based on t he m edical records. How do w e disput e t his kind of claim ?

Answ er: Discussions with the facility indicated that the patient came to the facility as a transfer from a different emergency setting to an inpatient status. The patient came in an ambulance after arranging for the transfer under EMTALA guidelines, so they were not considered stable by NSA definition and would still be protected from balance billing under the NSA The prohibition to balance bill for OON services would continue in the receiving facility until the patient was considered stable as outlined in the following excerpt from a CMSFAQ.

Frequently Asked Questions For Providers About The No Surprises Rules (cms.gov)

CMShas a page dedicated to the Independent Dispute Resolution (IDR) process: Payment disputes between providers and health plans | CMS

The NSA created protections against out-of-network balance billing and established a process, called independent dispute resolution, which providers (including air ambulance providers), facilities, and health plans can use to resolve payment disputes for certain out-of-network charges The following is an outline of that process

Not all items and services are subject to the Federal Independent Dispute Resolution process. Some states have their own balance billing laws or other laws that determine out-of-network payment amounts

The following resources can help determine whether items or services in a state are subject to the Federal process:

- Chart for Determining the Applicability for the Federal Independent Dispute Resolution (IDR) Process (PDF)

- Chart Regarding Applicability of the Federal Independent Dispute Resolution (IDR) Process in Bifurcated States (PDF)

If you have questions about the independent dispute resolution process or would like to report a potential violation of the process, contact the No Surprises Help Desk at 1-800-985-3059 from 8 a m to 8 p m EST, 7 days a week

Timelines for dispute resolution processes are counted in business days, defined as 8:00 a m to 5:00 p m , Monday through Friday, excluding federal holidays

Quest ion: Should a pat ient w ho w ill have $0 financial responsibilit y receive a good fait h est im at e?

Answ er: The good faith estimate (GFE) needs to clearly indicate the self-pay rates, including any discounts for which the patient would be eligible. If the provider knows in advance they will not be billing the patient they can use the newly created Abbreviated GFE That document will be available in the PDEwith a future enhancement Workers' Compensation is not considered a health plan, but rather uninsured, which is required to receive a good faith estimate. In the event the individual has a group health plan that will cover third party liability charges, the patient is considered insured and a GFEis not required. The same holds true for any third party liability situation

Quest ion: Does a pat ient have t o sign t he good fait h est im at e?

Answ er: No The good faith estimate is not a contract; thus, it does not require a signature

Quest ion: Are t here any not ices I m ust have t he pat ient sign for t he No Surprise Act or signage added?

Answ er: The only form that must be signed is the Notice and Consent when the patient chooses to receive services from an out-of-network provider or facility when they have the option of an in-network provider within that same facility. An out-of-network provider cannot require a Notice and Consent to balance bill if they are rendering ancillary services within a facility that has a contractual agreement with the patient?s health plan

PUBLICHEALTH EMERGENCY SETTO EXPIREMAY 11, 2023

On January 30, 2023, the Biden Administration announced that the Public Health Emergency (PHE) declared on January 27, 2020, will officially end on May 11, 2023

The end of the PHEwill coincide with the end of the National Emergency

On January 11th, HHSannounced that the PHE's 12th and most recent extension was extended until April 11, 2023 The Biden Administration, through the Office of Management and Budget (OMB), officially released a Statement of Administrative Policy on January 30th, 2023, providing the advanced 60-day notice before the termination of the PHE https://www whitehouse gov/wp-content/uploads/2023/01/SAP-H R-382-H J-Res -7 pdf

This notice allows healthcare providers and health systems time to shift from flexibilities and waivers offered during the pandemic.Providers are encouraged to review the COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers The CMSdocument addresses how the end of the PHEaffects flexibilities offered during the PHE https://www.cms.gov/files/document/covid-19-emergency-declaration-waivers.pdf

Among the waivers and flexibilities that will terminate with the end of the PHE:

- Critical Access Hospitals will be limited to 25 beds and a length of stay of 96 hours

- Temporary expansion locations allowed during the PHEfor hospitals, RHCs FQHCs and provider-based departments will end

- The 3-Day Prior Hospitalization for coverage of a SNFstay will resume

- Most administrative reporting and documentation requirements under 42 CFR§482 will no longer be paused

- The payment for COVID-19 specimen collection C9803 will be packaged into the payment for the COVID-19 testing

- Traditional Medicare and Medicare Advantage plans will resume with cost-sharing related to COVID-19 testing, testing-related services, and certain COVID-19 treatments IPPSHospitals will no longer receive a 20%reimbursement increase for treating inpatients with COVID-19

PUBLICHEALTH EMERGENCY SETTO EXPIREMAY 11, 2023

Medicare provided a list of 2023 Telehealth Services which may be downloaded from the Para Data Editor (PDE) by typing ?telehealth?in the summary tab CMSprovides additional information on which services may continue after the PHEEnds.

For each service CMSadded to the telehealth list to extend services during the PHE, Medicare states either the service will be extended through the remainder of 2023 or the provider may no longer provide the service through telehealth after 151 days of the end of the PHE.

Emergency Use Authorizations (EUAs) for drugs and treatments may continue beyond the end of the PHE.

https://www fda gov/emergency-preparedness-and-response/mcm-legal-regulatory-and-policy-framework/ faqs-what-happens-euas-when-public-health-emergency-ends

PUBLICHEALTH EMERGENCY SETTO EXPIREMAY 11, 2023

On February 1, 2023, CMSupdated its document on PHEblanket waivers and flexibilities for Hospitals and CAHs: https://www cms gov/files/document/hospitals-and-cahs-ascs-and-cmhcs-cms-flexibilitiesfight-covid-19.pdf

CMSwill continue to provide updated information through its Coronavirus Waivers & Flexibilities page https://www cms gov/coronavirus-waivers