No Surprises Act

[Sushirolls]

January 1st this goes live.
I'm trying to wrap my head around how much damage this is going to be and if able to do it in my small solo insurance based practice.
Or will this be the death knell that pushes me into cash only?

I haven't yet sat down to read and mentally process this yet.

Has any one else reviewed this yet and what it means?

I originally thought this pertained only to Out Of Network, but now I think this applies to all, including in network?

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[capacityconsult]

There's no reason the law should affect physicians in network, the law applies to out of network situations specifically. It's designed to help patients not receive ridiculous bills from hospitals/third party charges that they believed would be covered by their insurance.

https://www.ama-assn.org/system/files/2020-12/no-surprises-act-summary.pdf

 

[Sushirolls]

From that PDF, last page, the bolded is the part that has me concerned even as in network:

A plan must provide an advanced explanation of benefits in advance of the service containing the following information: o Whether the provider or facility is participating and, if so, the contracted rate. o If the provider or facility is out-of-network:  Information on how patient can find info on contracted physicians at facility;  The good faith estimate from the provider, if applicable;  A good faith estimate of the amount the plan is responsible for paying;  A good faith estimate of cost-sharing based on provider’s estimate and the amount to be applied to the patient’s out-of-pocket maximum and deductible;  A disclaimer that coverage is subject to medical management requirements, if applicable;  A disclaimer that the information is only an estimate and may be subject to change;  A statement that the patient may seek care from a participating provider or at facility.

 

[Sushirolls]

This random lawyer website write up summary:

What the No Surprises Act Means for Patients, Providers, and Payers

Learn how your health care organization can prepare for the No Surprises Act, which aims to mitigate surprise medical billing at the federal level.

www.mossadams.com

The parts I highlighted below and bolded seem to also including in network, non-emergency services, providers (i.e. and outpatient psychiatrist).

2. Provide Advanced Explanation of Benefits (EOB)​

Health plans and providers are required to provide a timely Advanced EOB notification in plain language. This Advanced EOB must include the following components:

• Whether the provider or facility is participating and, if participating, the contracted rate.

 

[calvnandhobbs68]

This random lawyer website write up summary:

What the No Surprises Act Means for Patients, Providers, and Payers

Learn how your health care organization can prepare for the No Surprises Act, which aims to mitigate surprise medical billing at the federal level.

www.mossadams.com

The parts I highlighted below and bolded seem to also including in network, non-emergency services, providers (i.e. and outpatient psychiatrist).

2. Provide Advanced Explanation of Benefits (EOB)​

Health plans and providers are required to provide a timely Advanced EOB notification in plain language. This Advanced EOB must include the following components:

• Whether the provider or facility is participating and, if participating, the contracted rate.

I mean the patients know the contracted rate a few weeks after the appointment when they get their EOB from the insurance company in the mail. It’s not like it’s a secret, it lays it out code by code specifically for you. What are you concerned about?

based on the AMA document seems like the onus is on the insurance plan, not the provider, to provide the advanced EOB, so that may be a misreading from the legal website.

Also this doesn’t seem to apply to outpatient in network doctors. From that same article:

Specifically, the act extends protection to the following types of services:

• All out-of-network emergency facility and professional services
• Post-stabilization care at out-of-network facilities until a patient can be safely transferred to an in-network facility
• Air ambulance transports, whether emergency or nonemergency in nature
• Out-of-network nonemergency services delivered at or ordered from an in-network facility unless the provider follows the notice and consent process

 

[Bartelby]

I think the concern for a private practice psychiatrist is flying over my head. What would be the issue with disclosure of the contracted rate?

 

[FlowRate]

From reading the AMA pdf I don't see where a contracted in-network doc has to do anything about this at all. That random lawyer article seems to overstep as most of this seems directed toward out of network facilities/providers and insurance companies.

It would be onerous to have to figure out a way to provide an EOB for every variation of every insurance plan you accept. I do not think that is likely to be the case.

 

[Mass Effect]

Would this apply at all to cash only practices even?

 

[NickNaylor]

Would this apply at all to cash only practices even?

Doubt it - all the language in the bill refers to participation in a "plan." Presumably you aren't participating in a "plan" if you're running a cash-based practice. And even if it's applicable, seems like this could be very easily solved by just disclosing your rate and, if you bill by time (rather than service), an estimated amount of time for new evaluations and follow-up visits.