No Surprises Act compliance: Sizing up the challenges
A WEDI forum addresses the difficulties in providing consumers with accurate estimates of healthcare expenses in advance of receiving services.
The No Surprises Act is based on the premise that cost-conscious consumers who get accurate healthcare price information before services are delivered will be empowered to make wiser decisions.
The challenges facing providers in their early efforts to comply with the Act by preparing simple, understandable and accurate price quotes to consumers were addressed at the WEDI Summer Forum in Chicago August 2 and 3.
Rob Tennant, vice president of federal affairs, WEDI
Ongoing challenges in contacting all appropriate providers and compiling an accurate cost estimate have prompted WEDI to suggest further delays in enforcement of the act.
Many healthcare players that are taking steps to meet the law’s requirements are struggling with several issues, including using standards to exchange price estimates, gathering all necessary information when multiple providers are involved and educating consumers about the law, speakers at the two-day event noted.
Basics of the law
Among its provisions, the No Surprises Act requires healthcare providers to offer good-faith cost estimates to self-paying or uninsured patients within three days of being requested or the service being scheduled, in part, to help avoid catastrophic “surprise” bills, such as for out-of-network services.
Portions of the law went into effect on January 1, although the Department of Health and Human Services has pushed back compliance enforcement action until all the necessary rules and regulations are in place and the industry is judged to be sufficiently ready to comply.
Beth Davis, vice president, Payerpath operations at Allscripts
“Several things in the new law seem not only unworkable…We believe it’s in the patient’s best interest, but how can we really get there?”
Provisions in the new law related to emergency services – when patients seek care immediately and don’t have the time to find an in-network provider – prohibit “balance billing,” said Michael Kolber, a partner at Manatt, a professional services firm. Balance billing is when a provider bills a patient for those charges not covered by insurance.
The law also requires the use of standard approaches for determining and regulating out-of-network rates for healthcare services while giving consumers a process for contesting charges. It sets out requirements for an advance explanation of benefits – which provides a good-faith estimate of charges for medical care – so that patients, especially self-pay or uninsured patients, can review the costs before care is provided.
Final rules on the independent dispute resolution process – a new way to adjudicate payment disputes with providers for certain out-of-network charges – and provisions for the advanced EOBs and related provisions of the Consolidated Appropriations Act are awaiting approval by the White House and could be released in the coming weeks, Kolber said.
In the meantime, healthcare organizations are moving forward in anticipation of what the final provisions of the act will look like, said Rob Tennant, vice president of federal affairs for WEDI. The organization, which advises the government on electronic data interchange issues, has formed a task force that’s focusing on areas of the law “that have not been spelled out,” Tennant says.
Among the difficult issues to address are:
- A lack of machine-readable files containing pricing information for hospitals and insurers.
- Variances between the preliminary “rough” estimates made through providers’ and insurers’ patient cost calculators/estimators and later, more accurate and formal estimates given to patients to comply with the No Surprises Act. Website-based calculators or price menus typically provide ballpark or low estimates for what patients could be billed for services, while good faith estimates come after an in-person examination and after patient-specific complications are factored into pricing.
- Current limited capabilities of healthcare organizations to produce accurate good faith cost estimates and advanced EOBs, as required by the law.
Patients seeking to compare costs among physician practices for a particular procedure may be given quick estimates over the phone before they’re examined by a doctor, which can lead to inaccuracies, said Beth Davis, vice president for Payerpath operations at Allscripts, a healthcare software vendor. When a patient is subsequently examined and a more exact estimate of costs is presented, those estimates may be substantially different, and that could form the basis for a patient appeal of charges, she noted.
WEDI has identified the complexities involved in determining which provider bears responsibility for compiling charges when multiple professional services are needed for complex procedures, Tennant noted. Ongoing challenges in contacting all appropriate providers and compiling an accurate cost estimate have prompted WEDI to suggest further delays in enforcement of the act.
Some providers have indicated that they’re concerned that good faith estimates will reveal pricing information to competitors, said Terrence Cunningham, director of administrative simplification policy for the American Hospital Association.
And technical issues can make providing accurate estimates difficult, he added. “Technology sophistication varies widely among providers. A lot of providers are struggling to get their arms around this because it is a new process.”
Davis of Allscripts added: “Several things in the new law seem not only unworkable, but unworkable out of the gate. It may take time and adjustments until the industry learns how to grapple with it. We believe it’s in the patient’s best interest, but how can we really get there?”
Challenges for providers, payers
At the WEDI event, several organizations described their challenges in complying with the Act.
HCSC – which operates Blue Cross/Blue Shield plans in five states – was able to “deliver a minimum viable product” offering cost estimates after it ensured that its practices were consistent among the plans it operates as well as with other Blues plans’ procedures, said Chatterjee Saugata, its senior director of business solutions.
At the University of Chicago, some financial counselors had difficulty gathering necessary information from electronic medical records they needed to make cost estimates, said Suzanne Lestina, executive director of access and revenue integrity for its healthcare operations.
“My financial counselors are not trained to read medical records, and they can’t read the doctor’s mind” when record notes are vague, Lestina said at the forum.
Even though the law has been in place since Jan. 1, consumer awareness is low, as demonstrated by a paucity of disputes over charges so far, Saugata and Lestina said. “Consumers really don’t have clarity on this. … We [often] need to spend a good amount of time to educate them,” Saugata said.