Health Systems + Hospitals, Physician + Specialty Practices

No Surprises Act Q&A: Understand out-of-network services

No Surprises Act Q&A: Understand out-of-network services

Waystar has covered all things about the No Surprises Act. First, we took a closer look at Good Faith Estimates. Now, our experts are digging deeper into the NSA as it applies to out-of-network service scenarios.  

We’re answering questions submitted by providers like you, helping clear up confusion + keep your organization in compliance.  

Handling out-of-network services is not as straightforward as it appears. Tricky situations can leave providers feeling unsure of how to proceed. However, seeing how the No Surprises Act applies to complicated, out-of-network scenarios can help you stay prepared. 

Keep in mind, always consult with your legal team, compliance department or trade association if you have specific questions as to how the No Surprises Act requirements pertain to your organization.   

 

Does the No Surprises Act apply if a patient is seen at an in-network hospital but the providers are out-of-network?   

If the facility or hospital is in-network and any of the professional providers are out-of-network, then yes—the No Surprises Act applies.  

For more information, refer to CMS’s document on balance billing for any exceptions. For more information about your organization’s specific situation, contact CMS directly at provider_enforcement@cms.hhs.gov. 

 

What if out-of-network providers simply have every patient sign a multipage waiver? Are all bases covered?  

A provider waiver does not apply to all insured patients and cannot be obtained from or on behalf of certain professional services. This includes services such as those provided by emergency room physicians, anesthesiologists, pathologists, radiologists, neonatologists, assistant surgeons, hospitalists and intensivists. 

According to CMS, “a patient (or an authorized representative) isn’t required to, nor should the patient (or their authorized representative), sign the consent form unless the patient is willing to waive these protections and understands or agrees they will be paying out of pocket for balance bills on out-of-network services.”  

There are also circumstances where balance billing is never allowed regardless of having the patient sign a waiver. For more information, refer to CMS documentation or contact CMS directly at provider_enforcement@cms.hhs.gov 

 

Can providers continue to charge out-of-network rates for services that are scheduled in advance?  

Yes, as long as the out-of-network notice and consent is signed and delivered for non-emergent services. For more information, refer to this CMS document

 

We are not interested in balance billing our out-of-network patients. Could we simply NOT engage in this process at all and remain in compliance with NSA? 

Requirements of the No Surprises Act will not apply if:   

  • A provider has a policy to write-off balances if the payer processed a non-emergent, out-of-network claim and the patient never receives a bill. A complaint would not be submitted by the patient and the provider has no exposure.   
  • The provider posts adjustments as stated on the payer’s remit for out-of-network, emergent cases. In this scenario, the provider has no exposure.   

Please consult with your legal team and contact CMS at provider_enforcement@cms.hhs.gov for official confirmation as to what is best for your organization.   

 

Is provider NPI or organization tax ID used to identify out-of-network or in-network services?

Generally, NPI is used by the payer to isolate out-of-network services. 

   

If a provider is out-of-network and the patient has out-of-network benefits, is the provider required to file with the insurance?  

Patients are protected from balance billing for: 

  • Emergency services. In situations where a patient has an emergency medical condition and gets emergency services from an out-of-network provider or facility, the most the provider or facility may bill is their plan’s in-network cost-sharing amount, such as copayments and coinsurance. This includes services that may be required to stabilize the patient’s condition, unless the patient gives written consent and gives up protections not to be balanced billed for these post-stabilization services. 
  • Certain services at an in-network hospital or ambulatory surgical center. When the patient receives services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill is the plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist or intensivist services. These providers can’t balance bill you unless the patient has waived their protections. 

For more information about balance billing protections, please refer to the CMS documentation and the model disclosure notice regarding patient protections against surprise billing.   

 

Be prepared for out-of-network services 

Knowledge is power. When out-of-network service scenarios throw you off, be armed with the right information. Leverage these insights so you can be confident you are staying in compliance with the No Surprises Act and out-of-network situations. 

When a question or concern arises, contact your legal team, compliance department or trade association. You can also get specific information for your organization’s situation by reaching out to CMS directly at provider_enforcement@cms.hhs.gov.  

Find this post helpful? Grow your understanding of Good Faith Estimates. 

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