How the “No Surprises Act” impacts provider directories, price transparency, & health coverage IDs

by Joseph Kennedy... 

The No Surprises Act was signed into law on December 27, 2020 as part of the Consolidated Appropriations Act of 2021 (H.R. 133; Division BB – Private Health Insurance and Public Health Provisions). The No Surprises Act addresses “surprise” medical billing at the federal level. Out-of-network billing, or “surprise medical bills” are usually the balance between what the individual’s insurer pays for the out-of-network care and what the provider charges for the services.

Simply put, the act states that patients should not be responsible for out-of-network costs they did not agree to pay.
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The Departments of Health and Human Services, Treasury, and Labor will be releasing regulations and guidelines for the implementation of these provisions before the largest sections of the legislation go into effect on January 1, 2022.

The impetus for change
The legislation is designed to address the challenge for patients which result from receiving unexpected medical bills attributed to gaps in insurance coverage for medical services provided by out-of-network providers at an in-network facility or hospital. This occurs most commonly from Emergency Department (ED) visits and second most commonly in-network hospital admissions.
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A study from the Kaiser Family Foundation (KFF), found that the number amount of “surprise medical billing” for ED visits increased from 32.3% to 42.8%. and increased from 26.3% to 42.0% for inpatient admissions between 2010 to 2016. KFF estimated that an 18% of ED visits and 16% of inpatient hospital visits resulted in a minimum of one out-of-network medical bill. 


What you need to know
The “No Surprises Act” calls for price transparency, consent for out-of-network costs, and accurate, accessible provider directory data.

The provider data management takeaway is that health plans will be required to establish a verification process to ensure accurate provider directories. In addition, they will need to enable a response protocol for individuals inquiring about the network status of a provider, and they are required to have publicly accessible provider databases.

Here are some additional highlights of what is required from providers and health plans effective January 1, 2022.

1. Both providers and health plans will be required to provide online price comparison tools that allow members/patients to compare expected out-of-pocket costs for items and services across multiple providers.
2. Provider directories must be accessible, have a verification process, and enable a response protocol for consumers with provider network questions.
3. Health plans are required to cover Emergency Department  services without any prior authorization and regardless of whether the provider is in or out of the health plan’s network.
4. Health plans must reimburse the provider directly and cannot instead route payment through the patient.
5. Any patient cost-sharing must count toward the patient’s deductible and/or out-of-pocket cost-sharing maximum at the in-network amount.
6. Patients/Consumers will only be liable for their in-network cost-sharing amount.
7. Providers and insurers will have an opportunity to negotiate reimbursement and access an independent dispute resolution when an agreement cannot be reached.
8. All co-pay, deductible, and out of pocket maximum information must be included on insurance identification cards (health ticket).

​The American Hospital Association (AHA) provides a detailed summary of the legislation which can be downloaded here.


The provider data management approach to "no surprises"
This comprehensive legislation addresses surprise medical billing at the Federal level also creates an additional burden for provider data management as defined in these three sections.
 
SECTION 107:  Transparency regarding in-network and out-of-network deductibles and out-of-pocket limitations on health coverage identification cards.
Reproduce digital and printed health coverage ID cards (health tickets) with clear cost transparency on all plan deductibles, including in-network and out-of-network deductible amounts; and the maximum limits on out-of-pocket costs, including in-network and out-of-network out-of-pocket cost limits.

​In addition, it is required to include a telephone number and web address for consumer assistance information, including information on in-network providers

Recommendations:
Enable digital data capture of consumer data and corresponding plan information via an online self-service health coverage ID solution. Ensure the visibility of all plan deductibles and out-of-pocket limits along with a telephone number and web address for consumer assistance.
 


SECTION 114: Maintenance of price comparison tool
Maintain online price comparison tools that will allow patients to compare expected out-of-pocket costs for items and services across multiple providers.
Recommendations:

• Enable online price comparison capabilities within the provider directory by creating charge, payment, and allowable reimbursement profiles for all providers and related services.
• Use ongoing analytics to gain insights to maximize claims related revenue cycle
• Balance provider cost-effectiveness with outcomes to support consumer decision-making

 

SECTION 116:  Protecting patients and improving the accuracy of provider directory
Health plans will be required to establish a verification process to ensure accurate provider directories. In addition, they will need to enable a response protocol for individuals inquiring about the network status of a provider, and they are required to have publicly accessible provider databases.
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Recommendations:

• Create a provider network data – “Source of Truth” via a master provider data index
• Mitigate data related risk & reduce costs by outsourcing provider data hosting
• Improve access and accountability to with single source of provider data
• Integrate an online chat solution within the provider directory to assist current and prospective clients to comply with regulatory requirements
• Access data driven analytics to further understand consumer utilization and response to chat solution
• Enable round the clock automated, personalized, and interactive chat responses aligned to the user journey, key regulatory requirements, and guided user experience

 

Perspecta is uniquely positioned to support health plans and providers in meeting and exceeding these new legislative requirements before the 2022 deadline. Perspecta is a provider data management industry leader, offering solutions that deliver optimized user experience, data accuracy, access, regulatory compliance, and return on investment.

P.S.: If you have questions about how the No Surprises Act, I'd be happy to chat and provide a FREE consultation. Feel free to schedule a meeting with me here.