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Hey everyone. Michael Miscoe with Miscoe Health Law with this week’s installment of ChiroSecure’s Growth Without Risk series. Had a lot of calls recently about the no surprises act and its implications to outpatient providers, including doctors for chiropractic. So I thought it would be a good time to review what this law is about and what we what you need to know about it.
Uncharacteristically, I did prepare some slides for this presentation that have links in. If you need a copy of these, you can get them from ChiroSecure following this presentation. If we could go to the next slide, the It’s important to understand what the scope of the law is because there’s some confusion about what this law actually applies to.
So to begin, let’s start with what a surprise medical bill is. I What are they trying to address here? And when a person that has some third party insurance plan, usually a group, a health plan seeks treatment from an out of network provider. The concept of being out of network means that provider has not signed a contract with the insurance company, agreeing to accept that particular payers allowance as their payment in full.
So in a ridiculous sense, let’s say you charged a thousand dollars for, let’s say a manipulation and. It went to the patient’s insurance company and the payers allowance was $50. It’s an out of network provider. The difference between your charge of a thousand and their allowance of 50, which would be $950 in theory becomes a responsibility of the patient.
And this context doesn’t arise too often in, out of network settings, but it most certainly arises with ER. Inpatient surgeries and whatnot where the patient doesn’t have the ability to query the provider. That’s seeing them as to whether they’re in network or not. So the focus of the law is it addresses balanced billing or the billing of that difference between your charge amount and the insurance company’s allowed amount.
What it thinks is reasonable for the service that you provided. But it, the law is focused on emergency services and certain hospital and ambulatory surgical center services. You can get information from HHS on the interim final rule. And what that means is there’s a statutory rule. And then the department of health and human services is the administrative agency adopts regulations implementing what Congress Has required by statute.
And what they do is they’ll publish a a preliminary rule. They open it up for comment. And what they’ve done at this point is published an interim final rule, meaning it’s not the final rule, but it is a interim rule that, that has the force and effect of law at this point. And that came into existence July 1st, 2021.
So this isn’t a brand new concept, but it is a concept. Outpatient providers increasingly have questions about in terms of whether they are subject to the rule or not. If we can go to the next slide.
The key element as it pertains to you, is that it bands these disallowed out of network charges from being billed to a patient without advance notice. So again, as I mentioned, emergency services inpatient surgery, AFC services in those scenarios, when the patient goes there in theory, They should be able to question who’s in network, who’s out of network, but in some cases you can’t and what happens is the patient goes into the hospital.
Maybe the hospital’s in network, but not all the providers that work in the hospital are in network. And what happens? The bills come in after the patient is discharged and. The insurance company pays what they’re going to pay, and then they get this monster bill from say, the surgeon or the ER department ER, physicians or something of that nature, because that particular physician was not in network.
And essentially. It’s a patient protection statute designed to insulate patients from unknowingly, encourage incurring these enormous bills for the disallowed portion of the physician service. Now in, in your setting as outpatient providers if you bill third-party insurance and you’re out of network, you have a couple of options.
One, you can treat the patient. As if you were an in network provider, meaning you would agree with the patient, not in a contract with the insurance company, but with the patient to accept the insurance company as allowances your payment in full and the quid pro quo similar to in network scenarios would be that the patient would agree to.
Fully pay any deductible or out-of-pocket expenses identified by their payer within a certain period of time, say 30 days from the date, the EOB comes down or payment in advance or something of that nature. Subject to reconciliation once the explanation of benefits comes down and those are legitimate scenarios and where, Eliminate the applicability of the no surprises act by virtue of the fact that you’re agreeing with the patient not to build them, those disallowed amounts assuming that they pay their out-of-pocket expenses identified by their payer.
Now, certainly if they don’t, then that disallowed amount then becomes live again. In which case they would have had for knowledge of it Many providers are doing out of non-covered services for cash under the S 8, 9, 9 0 code. This would not apply to any of those services. So anything that you do that isn’t covered the patient would have knowledge of that in advance.
They know that they’re responsible for the entire fee. And there is no third party insurance billing. To the extent that you are an out of network provider, you are doing third-party billing. And you don’t want to agree to accept that readable. In your fee. So let’s say more, realistically, your fee is $60.
They allow 50 and you want to charge the patient that $10 difference in addition to any deductible or co-insurance amounts that are identified, and maybe you don’t even accept assignment on the claim, the patient pays $60 and you either agree to submit a non assigned claim in which case the patient gets the check or you accept assignment and you post any payments and the patient pays the rest either way, or maybe even the patient sends in their own claim.
Bottom line is that you have to identify HHS and the no surprises act requires that you would alert the patient in advance as to the value of the disallowed amounts, that they will be responsible for. So that they can understand that your fee is higher than what the payer will allow. They have an exemplar form.
The link to that form is on the screen. And like I said, at the beginning, if you want a copy of these slides and the transcript all you have to do is ask the folks at ChiroSecure and they will provide that for you. Or you can just Google HHS. No surprises act form. And you can it’ll probably take you to this link.
And essentially the key is notice if you let’s say let’s go back to our ridiculous example, your fees, a thousand dollars. It doesn’t prohibit you from ever billing the patient, the difference between your fee and whatever they payer aloud. It just prohibits you from doing it without notifying the patient.
First in plain line. What that difference is going to be so that they can make a decision, whether they want to get the service from you, or they want to go to an in network provider or maybe another out of network provider that has a more reasonable fee. So notice is the key a lot of this Probably or is potentially handled by some of your financial policy documents that you have patients sign.
Certainly it is probably a great time. It’s near the beginning of the year for you to review those documents and make sure that they’re in compliance with the. Is a final point. I’d like to remind you, if you are doing services that insurance companies don’t cover, let’s say you do decompression treatment or you’re doing techniques that the the insurance companies Declare or are non-covered or experimental investigational.
And you charge the patients cash. You alert them in advance the services aren’t covered. Maybe you’re doing wellness care, palliative care, preventive care, supportive care, all the types of care that the insurance companies don’t cover because they’ve deemed them not medically necessary. In that case.
The notice is that the services aren’t. Okay. There’s no, sir. There’s no implications under the no surprises act for those kinds of services only because they’re not built a third party payer. So there isn’t a difference between the allowed them or the amount you charge in the allowed amount because the allowed amount is.
So that claim doesn’t need to be submitted interestingly enough, even if you were an in-network provider in most cases, your contracts do not require you to bill for non-covered services. So there, the notice is that the patient is receiving non-covered services and. Possibly, we can follow up with this presentation and go through some of those documents in terms of what that notice looks like patient acknowledgement, that the services aren’t going to be billed so that there’s no potential for a patient to claim confusion regarding the fact that their services were not covered.
Hopefully that provides you some useful information about the no surprises act. I don’t want to say it’s a big nothing burger, but if you’re out of network, certainly download that form. And possibly tailor it to the services that you’re providing so that your patients have appropriate notice.
And again, if you’re out of network billing, third party payers this has a direct applicability to you. If you’re in network or you don’t do any billing because you do only non-covered services for cash. The no surprises act really doesn’t have any real application to you. So I hope that was helpful.
And we look forward to seeing you next time next week tune in for Dr. Sam Collins, and he’ll have a, another interesting piece of information to share with you until next time. I’ll see you see you.