As of January, the No Surprises Act prohibits surprise billing for out-of-network services.
While Department of Health and Human Services understands providers will need some time to implement processes and procedures, healthcare organizations are expected to move toward complete compliance.
During a February webinar hosted by Becker's Hospital Review and sponsored by Xtend Healthcare, Linda Corley, chief compliance officer at Xtend, discussed challenges healthcare organizations have faced during these initial weeks as well as suggestions for moving forward.
Four insights:
1. Know your patient population. It is important to determine, if possible, the percentage of the patient population that represents out-of-pocket network services for a facility and physicians.
2. Healthcare organizations must revisit workflows and requirements for emergency and scheduled services. Many emergency rooms treat a mix of patients who are true emergencies, those seeking urgent care and individuals who require primary care during off-hours. "We need to have specific workflows for that patient who comes in as a true emergency." Ms. Corley said. For those requiring urgent or primary care, the self-pay good faith estimate (GFE) procedures should be followed. These include posting a notice of patient rights, obtaining consent for out-of-network services and providing a complete GFE for all uninsured or self-pay patients.
3. During initial implementation of the No Surprises Act, healthcare organizations have discovered four main stumbling blocks in planned procedures. These stumbling blocks are:
- Physician knowledge. Physicians must be trained on the definition of emergency, the specialty services that cannot be billed for balanced care, GFE requirements and documentation needed. "It's very important that everyone is on the same page with how an organization will identify an emergent patient, so those guidelines that are required for emergencies, and not required for scheduled patients, are followed," Ms. Corley said.
- Payment and arbitration. "Understand that the median contracted rate for a particular coverage plan is going to be the basis of payment," Ms. Corley said. "We need to document the specificity of the patient's acuity, or the particular degree of illness, as well as the intensity of the care received." Appropriate documentation can allow healthcare organizations to significantly raise collections during arbitration efforts.
- Patient understanding. Patients must understand that surprise billing cannot be waived for emergency services, air ambulance services, services provided by a nonparticipating provider if no participating provider is available, items for unforeseen medical needs or ancillary services.
- Time requirements. Finally, payment and successful arbitration depends on the timeliness of claim submissions and payment or denial actions.
4. GFE for uninsured or self-pay patients must be provided for scheduled services. Ms. Corley offered an example. "If we are scheduling an outpatient surgery, we need to include the surgeon's fee, both the technical and professional components of anesthesiology, costs of particular devices and so forth," she said. "We need to make sure all of this is included in our good faith estimate."
Xtend Healthcare helps clients navigate regulations such as the No Surprises Act. As healthcare organizations work on compliance in the future, they need to understand additional federal clarifications, evaluate procedures, adjust staffing, and improve revenue cycle team member communication.
To register for upcoming webinars, click here.