1 SEPTEMBER21, 2022 j our nale TheNSA SlideDeck A CorroHealth Company MoreDetails & Ten More Questions& Answers More
Quest ion: I have an ER visit w here w e are an in net w ork hospit al, but our ER provider w as out of net w ork We received an EOB w it h t he N830 RARC code, but it seem s w e got an out of net w ork paym ent for provider. Should I expect in net w ork paym ent , or a QPA am ount ? I am asking about t he out of net w ork provider t hat should be paid at in net w ork rat es correct ?
RARCN830 = Alert: The charge[s] for this service was processed in accordance with Federal/ State, Balance Billing/ No Surprise Billing regulations As such, any amount identified with OA, CO, or PI cannot be collected from the member and may be considered provider liability or be billable to a subsequent payer Any amount the provider collected over the identified PRamount must be refunded to the patient within applicable Federal/State timeframes. Payment amounts are eligible for dispute pursuant to any Federal/State documented appeal/grievance process(es). A list of RARCs related to the NSA can be found here: Rem it t ance Advice Rem ark Codes Relat ed t o t he No Surprises Act (cm s.gov)
Answ er: The in network facility should expect to receive the contracted rate for an ED visit The health plan is required to pay the OON ED provider the difference between the Out Of Network rate and the cost-sharing amount. The OON ED provider cannot balance bill the patient for anything over the copayment, coinsurance, or amounts paid toward a deductible. If the OON ED provider is not satisfied with the reimbursement from the plan, they are to negotiate a higher reimbursement with the plan. If they cannot agree upon an amount, then the IDRprocess is initiated to allow a third party to determine an acceptable reimbursement eCFR :: 45 CFR Part 149 -- Surprise Billing and Transparency Requirem ent s
NO SURPRISES ACTQUESTIONSAND ANSWERS More
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The plan or issuer: (B) Pays a total plan or coverage payment directly to the nonparticipating provider or nonparticipating facility that is equal to the amount by which the out-of-network rate for the services exceeds the cost sharing amount for the services (as determined in accordance with paragraphs (b)(3)(ii) and (iii) of this section), less any initial payment amount made under paragraph (b)(3)(iv)(A) of this section. The total plan or coverage payment must be made in accordance with the timing requirement described in section 2799A-1(c)(6) of the PHSAct, or in cases where the out-of-network rate is determined under a specified State law or All Payer Model Agreement, such other timeframe as specified by the State law or All Payer Model Agreement
(B) Items or services reasonably expected to be furnished by co providers or co facilities (as specified in paragraphs (b)(2) and (c)(2) of this section);
Answ er: A GFEis required for an uninsured individual who has services scheduled at least 3 days in advance. Generally, all providers and facilities that schedule items or services for an uninsured (or self pay) individual or receive a request for a GFEfrom an uninsured (or self pay) individual must provide such individual with a GFE No specific specialties, facility types, or sites of service are exempt from this requirement.
Quest ion: My NSA link requires a diagnosis code?
Answ er: There are no provisions in the NSA that require a plan to reveal their in network rates
Quest ion: Are w e required t o supply a GFE for our clinic services?
(A) Items or services reasonably expected to be furnished by the convening provider or convening facility for the period of care; and
Answ er: A diagnosis code is one of the required data elements in an estimate
Quest ion: If a plan is out of net w ork and t hey pay us an am ount t hat seem s t oo low , are t hey required t o t ell us t heir in-net w ork rat e?
NO SURPRISES ACTQUESTIONSAND ANSWERS
eCFR :: 45 CFR Part 149 Subpart G -- Prot ect ion of Uninsured or Self-Pay Individuals
(1) A good faith estimate issued to an uninsured (or self pay) individual must include:
Content requirementsof a good faith estimate issued to an uninsured (or self-pay) individual.
(ii) Description of the primary item or service in clear and understandable language (and if applicable, the date the primary item or service is scheduled);
(iv) Applicable diagnosis codes, expected service codes, and expected charges associated with each listed item or service;.
(iii) Itemized list of items or services, grouped by each provider or facility, reasonably expected to be furnished for the primary item or service, and items or services reasonably expected to be furnished in conjunction with the primary item or service, for that period of care including:
(i) Patient name and date of birth;
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Quest ion: Do you have any inform at ion on w here w e should be using t he not ice and consent in regards t o NSA and w hen t hose w ould apply? Only during em ergency services and or an out of net w ork provider at an in net w ork facilit y?
Ancillary providers cannot balance bill patients who seek services at an in network facility
- Items and services related to emergency medicine, anesthesiology, pathology, radiology, and neonatology, provided by either a physician or non physician practitioner; Items and services provided by assistant surgeons, hospitalists, and intensivists;
A provider or emergency facility can issue a Notice and Consent for post stabilization services only if all the following requirements are met:
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NO SURPRISES ACTQUESTIONSAND ANSWERS
Answ er: Patients who electively seek non emergency services at an out of network facility, have no protections under the NSA, so the patient can be balance billed without signing a Notice and Consent. The Notice and Consent is issued to a patient who presents to an in network facility when the out of network provider wishes to balance bill a patient, when balance billing is not prohibited. Emergency Services can never be balance billed.
Ancillary services are defined as:
- Diagnostic services, including radiology and laboratory services; and Items and services provided by an out of network provider when there is no in network provider who can provide the item or service at the in network health care facility
We are seeking clarit y as you not ed t hat ?NSA is int ended t o prot ect t he pat ient from surprise balance bills w hen t hey are receiving scheduled services at an in-net w ork facilit y/ provider. They are offered no prot ect ion from balance billing w hen t hey schedule services at an out of net w ork facilit y/ provider. ?
CMSreleased a slide deck that explains the prohibitions on balance billing The link below will take you to that slide deck. The No Surprises Act ?s Prohibit ions on Balancing Billing (cm s.gov)
- Provide contact information for the appropriate office or person to initiate open negotiations
- Provide a statement certifying that: (1) The QPA applies for purposes of the recognized amount, and (2) each QPA was determined in compliance with the methodology outlined in the July 2021 interim final rules
- No conflicts of interest. - Sufficient information regarding in-network allowed amounts paid for relevant items/services furnished in the applicable geographic region
A third party database may be an eligible database if it satisfies all of the following conditions:
- Ability to distinguish amounts paid to participating providers and facilities by commercial payers from all other claims data. State all payer claims databases have been deemed eligible
Upon request of the provider, the payer must inform them of how the QPA was determined.
Provide a statement concerning initiating the 30 day open negotiations period and initiating the federal IDRprocess within 4 days of the end of open negotiations
Answ er: The payer determines the Qualifying Payment Amount (QPA) and shares that information on the claim.
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Quest ion: How do w e know how t he payer det erm ined how m uch t o reim burse?
- Information to identify which database was used to determine the QPA, if applicable If a related service code was used to determine the QPA for a new service code, information to identify which related service code was used
A payer can use databases to determine the QPA
- The July 2021 interim final rules require that plans and issuers: Provide the QPA for each item or service involved
- If applicable, a statement that the plan?s or issuer?s contracted rates include risk-sharing, bonus, penalty, or other incentive based or retrospective payments or payment adjustments for the items and services involved that were excluded to calculate the QPA
- Information about whether the QPA includes contracted rates that were not set on a fee for service basis for the specific items and services at issue and whether the QPA was determined using underlying fee schedule rates or a derived amount
NO SURPRISES ACTQUESTIONSAND ANSWERS
Where a plan or issuer does not have sufficient information to calculate a median contracted rate, the plan or issuer must determine the QPA using an eligible database
We have provided a link to a CMSslide deck that discusses the prohibitions on balance billing and provided two excerpts which discuss Lab services and balance billing. The No Surprises Act ?s Prohibit ions on Balancing Billing (cm s.gov)
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Specimen collected and processed by the OON Lab
The OON Lab is considered an ancillary service which is always prohibited from balance billing the patient. Must dispute payment with payer.
NO SURPRISES ACTQUESTIONSAND ANSWERS
- Specimen collected by an in-network (IN) provider and sent to an out-of-network (OON) Lab
Specimen collected and processed by an IN Lab, but a non covered service by the plan
There are no protections in the NSA for non covered services The patient can be balance billed.
The OON Lab is considered an ancillary service which is always prohibited from balance billing the patient Must dispute payment with payer
Quest ion: I have one m ore quest ion regarding insurance being out of net w ork for lab services Out of net w ork insurance is not paying and denying st at ing t hat ?services rendered by out of net w ork provider not covered? and t he am ount is not m ade pat ient responsibilit y. Can t his be bill t o pat ient or w e need t o disput e?
There are no protections in the NSA for a patient who electively receives services at an OON facility/provider. Patient can be balance billed.
Answ er: There are some factors to consider when discussing ancillary services and balance billing. Here are some scenarios:
Specimen collected by an OON provider and sent to an OON Lab
NO SURPRISES ACTQUESTIONSAND ANSWERS
It is never appropriate for an ancillary service to issue a Notice and Consent to the patient. I have provided an excerpt from the slide deck referenced above.
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Qualitox Lab sent this letter to providers stating they will invoice the provider for lost revenue since they can? t bill the patient. That letter can be viewed here: No Surprises Act (qualit oxlab.com ) Contact your legal team if you receive a similar letter from an ancillary provider
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Separately, the good faith estimate (GFE) must be provided in written form either on paper or electronically (for example, electronic transmission of the GFEthrough the convening provider?s patient portal or electronic mail), pursuant to the uninsured (or self pay) individual?s requested method of delivery.
NO SURPRISES ACTQUESTIONSAND ANSWERS
Quest ion: Does t he post ed not ice (on w ebsit es and in facilit ies) m eet t he requirem ent of providing t he ?Right t o Receive a Good Fait h Est im at e of Expect ed Charges? in WRITING or m ust t he w rit t en not ice be present ed t o t he pat ient in t he m anner t hey choose ? em ail vs m ail? Included is an excerpt from CMS 10791 docum ent w hich leads m e t o t his quest ion.
GFEs provided to uninsured (or self pay) individuals that are transmitted electronically must be provided in a manner that the uninsured (or self pay) individual can both save and print, and must be provided and written using clear and understandable language and in a manner calculated to be understood by the average uninsured (or self pay) individual.
Appendix 1 St andard Not ice: ?Right t o Receive a Good Fait h Est im at e of Expect ed Charges? Under t he No Surprises Act (For use by healt h care providers no lat er t han January 1, 2022) Inst ruct ions Under Sect ion 2799B 6 of t he Public Healt h Service Act , healt h care providers and healt h care facilit ies are required t o inform individuals w ho are not enrolled in a plan or coverage or a Federal healt h care program , or not seeking t o file a claim w it h t heir plan or coverage bot h orally and in w rit ing of t heir abilit y, upon request or at t he t im e of scheduling healt h care it em s and services, t o receive a ?Good Fait h Est im at e? of expect ed charges
Answ er: To clarify Information regarding the availabilit y of a ?Good Fait h Est im at e? m ust be prom inent ly displayed on the convening provider?s and convening facility?s website and in the office and on site where scheduling or questions about the cost of health care items or services occur
If a patient requests that the GFEinformation is provided in a format that is not paper or electronic delivery, like orally over the phone or in person, the provider/facility may provide the GFEinformation orally but must follow up with a written paper or electronic copy in order to meet the regulatory requirements
Answ er: This is the response to a similar question answered by CMS: Generally, all providers and facilities that schedule items or services for an uninsured (or self pay) individual or receive a request for a GFEfrom an uninsured (or self pay) individual must provide such individual with a GFE.
Answ er: CMSis not giving any guidance on how to prove that a Disclosure notice was given Facilities and Providers need to contact their compliance department to draft policies/procedure and guidelines to educate, train, and monitor staff for compliance.
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NO SURPRISES ANSWERS
ACTQUESTIONSAND
?Health care facility (facility)?means an institution (such as a hospital or hospital outpatient department, critical access hospital, ambulatory surgical center, rural health center, federally qualified health center, laboratory, or imaging center) in any State in which State or applicable local law provides for the licensing of such an institution pursuant to such law or is approved by the agency of such State or locality responsible for licensing such institution as meeting the standards established for such licensing.
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?Health care provider (provider)?means a physician or other health care provider who is acting within the scope of practice of that provider?s license or certification under applicable State law, including a provider of air ambulance services;
No specific specialties, facility types, or sites of service are exempt from this requirement. The terms ?health care provider (provider)?and ?health care facility (facility)?are defined in regulations for purposes of the GFErequirements for uninsured (or self pay) individuals as:
IQuest ion: If t he disclosure form t hat is required t o be given t o each pat ient w it h a group healt h plan how do w e prove t his w as given and t he pat ient cont inued t o go t hrough w it h t he appoint m ent ?
There may be variations in practice patterns, such as whether a specific provider or facility furnishes services to uninsured (or self pay) individuals, along with the types of items or services provided There are some items or services that may not be included in a GFEbecause they are not typically scheduled in advance and not typically the subject of a requested GFE(such as urgent, emergent trauma, or emergency items or services); however, to the extent that such care is scheduled at least 3 days in advance, a provider or facility would be required to provide a GFE For example, individuals will likely not be able to obtain GFEs for emergency air ambulance services, as these are not generally scheduled in advance. However, making these requirements applicable to providers of air ambulance services helps to ensure that individuals can obtain a GFEupon request or at the time of scheduling non emergency air ambulance services, for which coverage is often not provided by a plan or issuer and thus even individuals with coverage must self pay.
Quest ion: How does t he NSA apply t o LTACH facilit ies?
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Article Detail - JFPart A - Noridian (noridianmedicare.com)
Many providers under Medicare?s Jurisdict ion E and F (Noridian ? CA, HI, NV, AS, GU, MP, AK, AZ, ID, MT, ND, OR, SD, UT, WA and WY) were surprised and disappointed to learn recently that Noridian will recoup payments made between 7/1/2020 and 4/1/2022 on outpatient claims reporting HCPCS0202U (infectiousdisease(bacterial or viral respiratorytract infection), pathogen-specificnucleicacid (dna or rna), 22 targetsincludingsevere acuterespiratorysyndromecoronavirus2 (sars-cov-2), qualitativert-pcr, nasopharyngeal swab, each pathogen reported asdetected or not detected), as that code has been paid incorrectly due to a Noridian system issue.
NORIDIAN RECOVERSREIMBURSEMENTFOR0202U
To search for claims with 0202U, go to the CMStab at the top of the screen and enter that code in the first HCPCSgroup box Click ?Review 250 Matching Claims? This allows all claims with this HCPCSto populate, up to 250 claims. In order to pull all the claims into a spreadsheet, check ?Include Detail?and then ?Export All Matching Claims To Excel?.
PARA clients in the Noridian Jurisdiction can obtain an estimate of the amount Noridian will recoup for each prior quarter up to Q3 2021 by using the CMS t ab of t he PARA Dat a Edit or. Under the CMStab, users can review Medicare claims data (PHI redacted) by quarter through Q3 2021 (Q4 data expected to be added within 30 days )
NORIDIAN RECOVERSREIMBURSEMENTFOR0202U
On the spreadsheet, open the ?details?tab at the bottom of the spreadhseet. From here you can view line by line charges and rates, including the rate amount for 0202U (see next page)
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That paper also lists LCDs, drafted and finalized, some of which have expired The following LCD?s on multiplex testing remain in effect:
NORIDIAN RECOVERSREIMBURSEMENTFOR0202U
(Note: Critical Access Hospitals are paid on a cost-reimbursement basis, not the CLFS.)
PARA previously reported on the non-covered status of the Biofire® Respiratory Panel Coding in most Medicare jurisdictions in 2021: Biofire Respiratory Panel Coding and Coverage Update 4 1 2021 pdf (para hcfs com)
13 PARA Weekly eJournal: September 21, 2022 OnAugust 31,2022,theFDAamendedEmergencyUseAuthorizations(EUAs)for ModernaandPfizer toaccount for bivalent COVID-19boostersthat target both theoriginal coronavirusstrainandBA.4andBA.5Omicronsubvariants. Moderna's COVID 19 booster is authorized for patients ages 18 and older PfizerBioNTech booster is authorized for individuals ages 12 and older The EUA instructs providers to stop providing monovalent mRNA COVID-19 vaccines as boosters. Instead, providers should administer the bivalent boosters. https://www fda gov/news events/press announcements/coronavirus covid 19 update fda -authorizesmoderna-pfizer-biontech-bivalent-covid-19-vaccines-use/ NEW CODESFORMODERNA AND PFIZERBIVALENTCOVID BOOSTERS
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NEW CODESFORMODERNA AND PFIZERBIVALENTCOVID BOOSTERS
In anticipation of future FDA approvals, the AMA released additional codes for bivalent COVID 19 boosters administered to younger ages. The codes will become effective on the date of FDA approval.
15 PARA Weekly eJournal: September 21, 2022 NEW CODESFORMODERNA AND PFIZERBIVALENTCOVID BOOSTERS ParaRev offers additional COVID-19 vaccine guidance in our COVID-19 Vaccine Product and Administration Codes and our 2022 Comprehensive COVID-19 Guide papers.
Act got youwondering, dazed,confused, befuddled,bewildered anddownright perplexed?
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If you've never attended one of our free webinars, never fear. There's anot her one scheduled right around t he corner.
Registering is easy. Just scan the QRCode and sign up. Then get ready for some great information that will prepare you for what's ahead.
16 PARA Weekly eJournal: September 21, 2022 NO SURPRISES ACTQUESTIONSAND ANSWERS HastheNoSurprises
In this special issue of the eJournal we've assembled 20 quest ions from the hundreds of inquiries received during our No Surprises Act Webinars.
If you haven't yet signed up for our webinar, click the QRcode on the previous page and register. It's important. It's informative. And, most of all, it's free!
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Here's a sneak peek of the slide deck used in our regular No Surprises Act Webinar, along with TEN MORE questions and answers that are sent in each week!
Andnow,there'smore!
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Answ er: HHSwill exercise its enforcement discretion in situations where a GFEprovided to an uninsured (or self-pay) individual does not include expected charges from co-providers or cofacilities. In a similar question answered by CMSin an FAQ published 12/21/2021, CMS encourages convening providers and facilities to include a range of expected charges for items or services expected to be provided and billed by co-providers and co-facilities. PARA?s NSA tool allows for the inclusion of co providers?contact information so the uninsured individual can contact those providers directly to request a GFE
Quest ion: If co provider did not provide t he GFE t o convening provider, can convening provider not give t he co provider 's GFE?
Answ er: In instances where multiple providers might be responsible for furnishing care in conjunction with a primary item or service, the ?convening provider or facility?must provide a GFEto the uninsured (or self pay) individual, which includes items or services reasonably expected to be furnished by the convening provider or facility, and items or services reasonably expected to be furnished by co-providers or co-facilities.
NO SURPRISES ACTQUESTIONSAND
No later than one business day after scheduling the primary item or service or receiving a request for a GFE, the convening provider or facility must contact all co-providers and/or co facilities that will provide items or services in conjunction with the primary items or services and request GFEinformation including the expected charges for these items or services expected to be provided by the co provider or co facility.
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Quest ion: What happens if m ore t han one provider or facilit y is involved in providing a prim ary it em or service t o an uninsured (or self pay) individual?
The convening provider or facility is the provider or facility that is responsible for scheduling the primary items or services. Other providers or facilities that furnish items or services in conjunction with the primary item or service furnished by the convening provider or facility are considered ?co-providers?and ?co-facilities ?
We understand that it may take time for providers and facilities to develop systems and processes for receiving and providing the required information from co providers and co facilities 1 45 CFR149 610(a)(2) 3 Therefore, for GFEs provided to uninsured (or self pay) individuals from January 1, 2022 through December 31, 2022, HHSwill exercise its enforcement discretion in situations where a GFEprovided to an uninsured (or self pay) individual does not include expected charges from co providers or co facilities ANSWERS
In developing these interim final rules, HHS considered allow ing providers or facilities to provide the disclosure annually or only at the time a patient schedules a service, but wanted to ensure the timing of the disclosure was relevant to when the individual may experience a violation of the surprise billing protections. HHSencourages providers and facilities to provide individuals with the notice at a time that will maximize the notice's effectiveness.
NO SURPRISES ACTQUESTIONSAND ANSWERS
We note that nothing prohibits a co provider or co facility from furnishing the GFEinformation to the convening provider or facility before December 31, 2022, and nothing would prevent the uninsured (or self pay) individual from separately requesting a GFEdirectly from the co provider or co facility, in which case the co provider or co facility would be required to provide the GFEfor such items or services
Answ er: In the Interim Final Rules, Part 1, HHSwas considering allowing the disclosure notice to be given annually The final decision was to give the notice when it will have the most influence Giving the Disclosure at the beginning of a series of 10 treatments would be effective in informing the patient of their rights under the NSA.
Federal Regist er :: Requirem ent s Relat ed t o Surprise Billing; Part I
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Otherwise, during this period (January 1, 2022 through December 31, 2022), we encourage convening providers and facilities to include a range of expected charges for items or services expected to be provided and billed by coproviders and co facilities
Quest ion: If w e have pat ient s com ing in for infusions every day for 10 days in a row , w e only regist er t he pat ient one t im e and have t hem sign one consent for t he durat ion of t he infusions How ever, w e do subm it individual claim s for each DOS Do w e need t o provide t hem t he Disclosure Not ice every day t hey com e in or w ould one disclosure not ice suffice in t his case?
These disclosures are critical to helping raise awareness and enhance the public's understanding of state and federal balance billing protections. The purpose of these disclosures is to empower individuals to better understand the balance billing protections afforded under applicable state and federal law. In addition, these disclosures are important in ensuring individuals are able to identify violations of these interim final rules and related state law requirements and, if necessary, file complaints against providers and facilities
(d) Timing of disclosure to individuals. A health care provider or health care facility is required to provide the 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 no later than the date and time on which the provider or facility requests payment
Providers and facilities must issue the disclosure notice no later than the date and time they request payment from the individual (including requests for copayment 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
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Answ er: All individuals covered by a group health plan, and requesting that a claim be submitted to that plan, must receive a Disclosure Notice before the provider can request co-pays, or if not requesting a co-pay, before a claim is submitted to the plan.
(1) With respect to the required disclosure to be posted on a public website, the information described in paragraph (b) of this section, or a link to such information, must appear on a searchable homepage of the provider's or facility's website A provider or facility that does not have its own website is not required to make a disclosure under this paragraph (c)(1)
(2) With respect to the required disclosure to the public, a provider or facility must make public the information described in paragraph (b) of this section on a sign posted prominently at the location of the provider or facility A provider that does not have a publicly accessible location is not required to make a disclosure under this paragraph (c)(2).
NO SURPRISES ACTQUESTIONSAND ANSWERS
Quest ion: We have a clinic t hat w e offer t o em ployed individuals t hat w e pay $25 t o be seen for sick visit s. All have our hospit al insurance and claim s are subm it t ed t o t hem for w ellness visit s and t here is no cost t o em ployees for t hose Would w e need t o provide t he Disclosure Not ice t o t hose em ployees w ho ut ilize t his clinic since t hey are covered by t he hospit al group healt h plan?
(3) With respect to the required disclosure 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, a provider or facility must provide the information described in paragraph (b) of this section in a one page (double sided) notice, using print no smaller than 12 point font The notice must be provided in person or through mail or email, as selected by the participant, beneficiary, or enrollee
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.
eCFR :: 45 CFR 149 430 Provider and facilit y disclosure requirem ent s regarding pat ient prot ect ions against balance billing Required methods for disclosing information Health care providers and health care facilities must provide the disclosure required under this section as follows:
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(d) Timing of disclosure to individuals A health care provider or health care facility is required to provide the 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 no later than the date and time on which the provider or facility requests payment from the individual, or with respect to an individual from whom the provider or facility does not request payment, no later than the date on which the provider or facility submits a claim to the group health plan or health insurance issuer. ANSWERS
Quest ion: Is t his present at ion available t o dow nload? Answ er: All Q&A documents and recorded webinars can be found on the Bulletin Board at w w w.pararevenue.com NO SURPRISES ACTQUESTIONSAND
Thiswouldbemorethan thein-network ratebut it isdefinedby the plan/policy.
NO SURPRISES ACTQUESTIONSAND
Answ er: This is a question that AHA and HFMA have posed to CMSand the tri-agencies and are awaiting clarification. On a similar note, in a tiered network, the provider is considered in network at all levels, and therefore the ban on balance billing and conditions on cost sharing to the in network amount provisions do not apply Any cost sharing for tier 1 or tier 2 providers would be in-network and not applicable to No Surprises... so although not real helpful on your direct question... hoping this may help you or someone. ANSWERS
Quest ion: Now here is anyone addressing t hat m ost em ployer policies have a defined copay or deduct ible t hat applies t o out -of-net w ork If w e bill t he pat ient t he defined "out of net w ork" am ount (not balance billing), do w e have t o provide any not ice t o t hem ? This w ould be m ore t han t he in net w ork rat e but it is defined by t he plan/ policy.
Onasimilar note,inatierednetwork, theprovider isconsideredinnetwork at all levels,andthereforethebanon balancebillingandconditionson cost-sharingtothein-network amount provisionsdonot apply.
47 PARA Weekly eJournal: September 21, 2022
addressingthat most employer policieshavea definedcopay or deductiblethat appliesto out of network.
Nowhereisanyone
Thisisaquestionthat AHA and HFMA haveposedtoCMSandthe tri-agenciesandareawaiting clarification.
Any cost-sharingfor tier 1 or tier 2 providerswouldbein-network and not applicabletoNoSurprises...so althoughnot real helpful onyour direct question...hopingthismay help youor someoneelse.
If webill thepatient the defined"out of network" amount (not balance billing),dowehaveto provideany noticeto them?
48 PARA Weekly eJournal: September 21, 2022
Quest ion: Please confirm t hat NSBA does not apply in sit uat ions w here t he facilit y and provider(s) are out of net w ork
NO SURPRISES ACTQUESTIONSAND ANSWERS
Answ er: Under the No Surprise Act provisions related to non emergent items or services scheduled at an out of network facility with an out of network provider, at this time, a notice and consent along with a good faith estimate is not required under the Act provisions. That is not to say that it is not a best practice to provide an estimate for what the patient will owe when seeking non emergent care at an out of network facility with an out of network provider
Answ er: Yes The No Surprises Act provisions do not apply to scheduled services at out-of-network facilities, only to in-network facilities with an out-of-network provider performing the service.
Quest ion: I had a com plet ely different underst anding of one of your first point s and w ould appreciat e confirm ing w hat I heard. If t he facilit y and t he provider are bot h out of net w ork, e g w e don't accept X insurance at all no consent is required? Not even a confirm at ion t o t he pat ient so t hey know t he facilit y is OON? EG OP hospit al specialist bot h don't accept insurance - no consent required?
Answ er: This is correct, with the exception of emergent care For emergent items and services provided at any facility, emergent care out of network balance billing is prohibited However, for scheduled out-of-network services, an out-of-network convening provider with an out of network co provider or co facility is not required to provide a consent or a good faith estimate before balance billing a patient for out of network items or services this would not be a "surprise" since the patient sought care at an out of network convening provider/facility
Quest ion: I am a lit t le unclear on ancillary services st ill If a pat ient schedules at an OON facilit y and is non-em ergent , can w e balance bill ancillary?
Answ er: The GFEis provided to the patient by the convening provider. The convening provider is described as the provider who is scheduling the service. If the office is scheduling the patient for the Lab draw at least 3 business days in advance, and will be billing the patient for the Labs, the office must include the Lab charges on the GFE
Quest ion: Is t here any exclusions in t he event t he service is an urgent case? For exam ple, a self-pay pat ient having an urgent surgery t hat is scheduled m ore t han 3 days out ? Do t he t im e fram es st ill apply regardless?
Answ er: Time frames are based on when the service is scheduled There are no exceptions to the severity of the case or how it is identified as a needed service.
Convening healt h care provider or convening healt h care facilit y (convening provider or convening facilit y) means the provider or facility who receives the initial request for a good faith estimate from an uninsured (or self pay) individual and who is or, in the case of a request, would be responsible for scheduling the primary item or service (iii) Co-health care provider or co-health care facility (co-provider or co-facility) means a provider or facility other than a convening provider or a convening facility that furnishes items or services that are customarily provided in conjunction with a primary item or service
(A) Written in a clear and understandable manner, prominently displayed (and easily searchable from a public search engine) on the convening provider's or convening facility's website, in the office, and on-site where scheduling or questions about the cost of items or services occur;
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eCFR :: 45 CFR Part 149 Subpart G Prot ect ion of Uninsured or Self Pay Individuals
Quest ion: If physician's office draw s blood and sends t o t he lab t o be t est ed w ho should provide t he GFE t o pat ient ? Does physician's office provide GFE t o pat ient in t his sit uat ion?
NO SURPRISES ACTQUESTIONSAND ANSWERS
Requirem ent s of providers and facilit ies (1) Requirements for convening providers and convening facilities. A convening provider or convening facility must determine if an individual is an uninsured (or selfpay) individual by: (i) Inquiring if an individual is enrolled in a group health plan, group or individual health insurance coverage offered by a health insurance issuer, Federal health care program (as defined in section 1128B(f) of the Social Security Act), or a health benefits plan under chapt er 89 of t it le 5, Unit ed St at es Code; (ii) Inquiring whether an individual who is enrolled in a group health plan, or group or individual health insurance coverage offered by a health insurance issuer or a health benefits plan under chapt er 89 of t it le 5, Unit ed St at es Code is seeking to have a claim submitted for the primary item or service with such plan or coverage; and (iii) Informing all uninsured (or self pay) individuals of the availability of a good faith estimate of expected charges upon scheduling an item or service or upon request; information regarding the availability of good faith estimates for uninsured (or self-pay) individuals must be:
Quest ion: Do NSA Only users have t he opt ion of adding addit ional services? Can NSA Only users provide est im at es for m ult iple services on one GFE? Answ er: NSA Only Users have access to the Extract/Table 2 to create Custom Claims.
(B) When a primary item or service is scheduled at least 10 business days before such item or service is scheduled to be furnished: Not later than 3 business days after the date of scheduling; or
50 PARA Weekly eJournal: September 21, 2022
(B) Orally provided when scheduling an item or service or when questions about the cost of items or services occur; and (C) Made available in accessible formats, and in the language(s) spoken by individual(s) considering or scheduling items or services with such convening provider or convening facility.
(iv) Convening providers and convening facilities shall consider any discussion or inquiry regarding the potential costs of items or services under consideration as a request for a good faith estimate; (v) Upon the request for a good faith estimate from an uninsured (or self pay) individual or upon scheduling a primary item or service to be furnished for such an individual, the convening provider or convening facility must contact, no later than 1 business day of such scheduling or such request, all co-providers and cofacilities who are reasonably expected to provide items or services in conjunction with and in support of the primary item or service and request that the co providers or co facilities submit good faith estimate information (as specified in paragraphs (b)(2) and (c)(2) of this section) to the convening provider or facility; the request must also include the date that good faith estimate information must be received by the convening provider or facility; (vi) Provide a good faith estimate (as specified in paragraph (c)(1) of this section) to uninsured (or self pay) individuals within the following time frames:
(A) When a primary item or service is scheduled at least 3 business days before the date the item or service is scheduled to be furnished: Not later than 1 business day after the date of scheduling;
(C) When a good faith estimate is requested by an uninsured (or self pay) individual: Not later than 3 business days after the date of the request
NO SURPRISES ACTQUESTIONSAND ANSWERS
For individuals who, at the time of scheduling or request, are not uninsured (or selfpay), HHShas indicated in guidance that it will defer enforcement of the requirement under PHSAct section 2799B?6, as added by section 112 of division BB of the CAA, that providers and facilities provide a GFEto such individual?s plan or coverage, until rule making to implement this requirement is adopted and applicable
3 This means that until further rule making to implement this requirement is adopted and applicable, HHSwill not enforce against providers and facilities that do not provide GFEs to plans and issuers for individuals who are not uninsured (or self pay), as defined in 45 CFR 149 610(a)(2)(xiii), at the time the individual schedules or requests the GFEfor the items or services expected to be furnished.
We encourage providers and facilities to inform patients when scheduling items or services or responding to a request for a GFEthat they should contact their provider if any information related to their appointment, including their insurance status, changes in advance of the appointment, so that a new GFEcan be provided, if necessary.
In situations where a provider or facility who has previously determined that an individual was not uninsured (or selfpay) becomes aware that an individual is uninsured (or selfpay) fewer than 3 business days in advance of the scheduled furnishing of items or services, nothing in the GFE regulations at 45 CFR149 610 require that the provider or facility provide a GFEto such an individual, or reschedule an appointment to allow for the provision of a GFEto such an individual.
51 PARA Weekly eJournal: September 21, 2022
Answ er: No When an individual schedules an appointment with a provider or facility, or upon request, the provider or facility must inquire if the individual is uninsured (or selfpay) If the individual is uninsured (or-self pay) at that time, the provider or facility must provide a GFEto the individual consistent with the requirements in 45 CFR149.610.
ACTQUESTIONSAND ANSWERS
Answ er: The NSA provision for a GFEis only required for uninsured patients or those who will not be submitting a claim (self pay) Insured individuals can be directed to (or assisted with using) the Price Transparency Tool (PTT) to determine the cost of services.
Quest ion: At t his t im e w hen t hey call for an est im at e is it only for t he uninsured t hat w e are required t o prepare t he GFE or for insured as w ell?
Quest ion: Suppose a provider or facilit y did not provide an individual w it h a GFE at t he t im e t he individual scheduled an it em or service because she w as not uninsured (or self-pay) at t hat t im e, but w hen she arrives for t he scheduled it em or service t o be furnished, her insurance st at us has changed such t hat she is now uninsured (or self pay). Must t he provider or facilit y provide a GFE t o t he individual prior t o providing t he it em or service, even if it m eans rescheduling t he it em or service for a lat er dat e?
NO SURPRISES
Quest ion: Will you be adding a ?Port al? opt ion along w it h Mail and Em ail?
Answ er: That request will be taken into consideration.
Quest ion: Are any providers set t ing up a unique ins plan code w here a GFE has been provided t o cont rol billing for m ore t han $400? Any ot her syst em flags you use t o m anage t hese pat ient encount ers?
Answ er: Billed charges should reflect the services provided It?s not necessary to keep the billed charges under $400 if they can be justified as medically necessary and could not have been anticipated in advance. The GFEis only as estimate of reasonably expected charges. There is a disclaimer that informs the patient that billed charges may exceed the estimate Not all bills exceeding the $400 threshold will be disputed The patient will initiate the dispute if they choose
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NO SURPRISES ACTQUESTIONSAND ANSWERS
Answ er: This request has been submitted to the Development team for discussion. The provider information is pulled by NPI number so multiple locations cannot be associated with one NPI. Any manual address changes will be saved and could potentially result in an incorrect address on future GFEs More information will be provided after the Development team finds a good resolution
Quest ion: For facilit ies w it h m ult iple locat ions can w e m anually change t he address on t he GFE?
Answ er: This question has been submitted to CMSfor clarification The GFEdata elements list future services as a requirement yet the template for the GFE, which CMSstates meets compliance, does not allow for entry of charges for future visit Will update when CMSresponds
Quest ion: Pat ient has cat ast rophic plan only (not show n t hrough eligibilit y, not com m unicat ed by insurance prior t o scheduled procedure) Hospit al called payor t o obt ain aut h for hem orrhoidect om y, but insurance st at ed no aut horizat ion w as needed. EOB cam e in as non covered procedure. Can t he hospit al bill pat ient ?
Answ er: If the catastrophic plan is through a health plan in which the facility has a contract, yes, they can bill the full amount as patient liability. If they don? t have a contract, yes, they can bill the full amount because OON patients have no protections under the No Surprises Act.
Quest ion: Several t im es in t he NSA it is m ent ioned t hat Medicare beneficiaries are not affect ed by t he NSA because Medicare has prot ect ions in place. I am request ing clarificat ion on t hose Medicare services t hat are st at ut orily excluded, covered under t he HINN and covered by an ABN These services are t echnically being supplied as self pay services Are t he HINN and ABN form s enough t o prot ect t he Medicare beneficiary or w ould t hey qualify for a GFE as a self-pay service? Response received on 04/ 18/ 2022
NO SURPRISES ACTQUESTIONSAND ANSWERS
53 PARA Weekly eJournal: September 21, 2022
Answ er: The requirements of the No Surprises Act, including the requirement to provide a good faith estimate to uninsured or self-pay patients, do not apply to individuals enrolled exclusively in Medicare. The Medicare program has its own protections against surprise bills.
Answ er: PARA must make those changes.
Quest ion: Does t he GFE need t o include any "fut ure" visit s/ services t hat m ay reasonably be expect ed w it h t he prim ary service?
Quest ion: Can w e updat e our uninsured discount or does PARA have t o do t his?
54 PARA Weekly eJournal: September 21, 2022 This is it .Par aRev hascompl et ely updat edit s Compr ehensive COVID-19Guide.TheGuidecontains detail edinfor mat ionabout bil l ingandcoding,t est ingandot her guidancer el at edt oCOVID-19. It's online. You can download it by clicking the image to the right, or by clicking the URL here: https://apps.parahcfs.com/para/ Documents/ 2022%20Comprehensive% 20Covid-19%20Guide pdf COMPLETELY UPDATED: COMPREHENSIVECOVID 19 GUIDE
55 PARA Weekly eJournal: September 21, 2022 MLN CONNECTS PARA invit es you t o check out t he m lnconnect s page available from t he Cent ers For Medicare and Medicaid (CMS) It 's chock full of new s and inform at ion, t raining opport unit ies, event s and m ore! Each w eek PARA w ill bring you t he lat est new s and links t o available resources Click each link for t he PDF! Thursday, Sept em ber 8, 2022 New s Make Your Voice Heard Request for Information Seeks Public Comment to Promote Efficiency, Reduce Burden, & Advance Equity within CMSPrograms - Enhancing Oncology Model to Improve Cancer Care: Apply by September 30 - Revision to National Coverage Determination (NCD) 240 2 (Home Use of Oxygen) to Align to 1834(a)(5)(E) of the Social Security Act Claim s, Pricers, & Codes Billing for Hospital Part B Inpatient Services National Correct Coding Initiative: October Quarterly Update MLN Mat t ers®Art icles - Changes to the Laboratory National Coverage Determination (NCD) Edit Software for January 2023 - Quarterly Update for Clinical Laboratory Fee Schedule (CLFS) and Laboratory Services Subject to Reasonable Charge Payment ? Revised
56 PARA Weekly eJournal: September 21, 2022 Therew ereSIX new or revised Transmittalsreleased thisw eek. To go to thefull Transmittal document simply click on thescreen shot or thelink. 6 t r ans mit t al s
57 PARA Weekly eJournal: September 21, 2022 TRANSMITTAL R11590CP
58 PARA Weekly eJournal: September 21, 2022 TRANSMITTAL R115604CP
59 PARA Weekly eJournal: September 21, 2022 TRANSMITTAL R11601CP
60 PARA Weekly eJournal: September 21, 2022 TRANSMITTAL R411599CP
61 PARA Weekly eJournal: September 21, 2022 TRANSMITTAL R11600CP
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TRANSMITTAL
R11596CP
63 PARA Weekly eJournal: September 21, 2022 1 m edl ear ns Therew asONEnew or revised MedLearnsreleased thisw eek. To go to thefull Transmittal document simply click on thescreen shot or thelink.
64 PARA Weekly eJournal: September 21, 2022 MEDLEARN MM12870
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