Any provider who hears about “surprise billing legislation” or the “surprise act of 2022” is bound to fear the worst. However, in this case, mandated changes to practice management could be a good thing. Patients and oncology providers — especially those who offer affordable, patient-centric care — can benefit from the new rules governing out-of-network costs. Here’s an overview of the No Surprises Act and how it affects oncology practices.
The No Surprises Act Means No Surprise Billing
Life is full of unpleasant surprises. Maybe you once had severe chest pains or your spouse was hurt in a car accident. Perhaps one of your kids sustained a head injury. If you sought treatment at the emergency room, you probably remember another unpleasant surprise: the sticker shock and outrage you felt when the bills rolled in.
Surprise medical billing, in which patients receive care from providers they had no opportunity to choose, is an issue in around 20% of ER visits. It happens almost as often in nonemergency treatment settings.
The No Surprises Act, or NSA, took effect in January 2022. For a federal law, it has a refreshingly understandable name. It was designed to protect patients from unexpected out-of-network costs.
Most insured people have planned for an emergency. They’ve located doctors and hospitals that are in-network on their health plans. However, many wrongly assume that all necessary services are covered in a crisis. Even in non-emergency settings, they presume that certain ancillary services — like X-rays or anesthesia — are covered if the hospital or clinic is in-network.
Just because a facility is in-network doesn’t mean that certain professionals there are. That’s how patients got blindsided by out-of-network costs in the past. Who has the time to compare shop heart surgeons in an emergency?
Even in planned cancer treatment, like ongoing care at an oncology practice, patients can’t possibly anticipate every service or medical device they might need down the road. That’s why surprise medical billing was so unethical.
New Billing Regulations in the Surprise Act of 2022
The No Surprises Act is part of the Consolidated Appropriations Act of 2021. The goal of the groundbreaking legislation is to make billing more transparent and equip patients to make informed healthcare decisions. Several features promote these objectives.
In emergency care, out-of-network costs can’t exceed a patient’s in-network cost-sharing price if the patient didn’t choose between in-network and out-of-network services. That’s a mouthful, but it simply means that patients can’t be billed at out-of-network rates unless they deliberately choose out-of-network professionals or services.
Let’s say that you suffered a nasty bump to the head, and the out-of-network specialist on duty treated you. Under the NSA, unless you specifically requested this specialist, you must be billed at your health plan’s in-network rate.
In non-emergency care, certain out-of-network services are now billed at in-network, cost-sharing amounts. They include lab work, radiology, pathology, neonatology, and anesthesiology. This new billing regulation applies even when a patient knows the services are out-of-network. It also applies to off-premise services like specialized imaging.
Providers and health plan administrators can negotiate reimbursement for balances that exceed cost-sharing amounts. Independent Dispute Resolution might be necessary when an agreement can’t be reached.
Changes in Practice Management for Oncology Providers
Transparency in billing should be a high priority for medical practice management.
To that end, oncology providers must inform patients about costs and deductibles. Insurers and providers must keep directories up to date and teach patients how to access information. Patients must be aware of their options and given good-faith estimates for out-of-network treatments.
Requirements must be met on a timely basis. For example, patients may voluntarily waive NSA protections and choose out-of-network services. However, they must be informed of the additional costs within 72 hours of treatment.
The surprise billing legislation affords other rights to patients. They may dispute bills that exceed the good-faith estimate by $400 or more. They should expect to receive information in a language they can understand. They should be notified of their protections under the NSA, and the notice should include contact information for government agencies that enforce the law.
Independent Dispute Resolution, or IDR, might pose the most significant challenge of all the changes associated with surprise billing laws. If stalled negotiations go into arbitration, oncology practice management will have to follow a strict timeline. If you miss deadlines, your practice could fail to recoup costs or face steep fines.
Incentives and Benefits for Oncology Practice Management
No one denies that the NSA does a little more work for people in medical practice management. However, the legislation is overwhelmingly a good thing. It even garnered bipartisan support, and that’s saying something these days.
Yes, there are legal and financial incentives for complying, but there’s more to it. Even medical workers are patients now and then. Making healthcare costs more understandable benefits, everyone.
Verdi Oncology is an oncology practice management company partnering with practices, physicians, and hospitals to provide affordable, value-based cancer care to patients and their families. Contact us to learn more about joining our network.