A Look into the Current State of the No Surprises Act

THE CONNXION VOLUME 1, ISSUE 05

 

Given the name, the No Surprises Act (NSA) is fairly self-explanatory—until it isn’t. Like most things in the healthcare space, the nuance and complexity surrounding the transparency-concerned bill can be difficult to navigate. Keeping up with any new updates and changes in regulations resulting from it can be even trickier. To make things clearer, WLT has taken a deep dive into the NSA for your benefit, keeping on top of the latest developments.

To start with, let’s look at why the NSA is necessary in the first place.

To better understand the NSA, it helps to also understand the Transparency in Coverage Rule. Designed with the intention of making pricing information for healthcare-related services more transparent for consumers, the requirements of this rule seek to reduce the secrecy behind healthcare-related pricing to empower consumers with the information they need to make informed healthcare decisions.

The name alone suggests why the Transparency in Coverage Rule is necessary, and the need for heightened transparency becomes even more apparent when looking into the No Surprises Act. The NSA originated as a direct mandate to combat surprise medical bills. While medical bills are never something anyone is particularly happy to receive, getting stuck with a bill you didn’t expect can be considerably—and in some cases, devastatingly—worse. These can occur when you see a doctor or other health care provider. You may have to pay out-of-pocket costs like copayment, coinsurance, or a deductible after the visit. Worst case scenario, you may owe the entire bill, if the provider or facility you visit isn’t in your health plan’s network.

The latter tends to be one of the bigger factors in surprise medical billing. Unexpectedly receiving care from an out-of-network provider or facility can result in a hefty bill, seemingly out of nowhere. This is often the case when a patient has no prior notice or no ability to choose the emergency room, ambulance providers, or physicians that will be treating them.¹ With the already convoluted world of healthcare, this isn’t exactly a rare issue: studies reveal that about one in five emergency room visits patients make are out-of-network.²

Unfortunately, these costs are most often out of patients’ control. Even beyond lacking the control to choose, people are rarely thinking about keeping track of what their insurance covers or doesn’t in the event of an emergency.

Looking to provide a solution for these costs, the Transparency in Coverage Rule and No Surprises Act aim to make information more available by giving consumers the tools they need to access pricing information, requiring private health plans to cover out-of-networks claims, applying in-network cost-sharing instead. This applies to job-based plans, non-group plans, and grandfathered plans. Additionally, the NSA prohibits doctors, hospitals, and other covered providers from billing patients for more than the in-network cost-sharing amount for those surprise medical bills, while also providing a process for negotiating between plans and providers to determine the payment amount for out-of-network surprise medical bills.

With the latest federal protections, the NSA also applies to surprise bills resulting from:

• Emergency Services
• Post-Emergency Stabilization Services
• Non-Emergency Services Provided at In-Network Facilities³

While the NSA is a recent development, the results are already visible. A Blue Cross Blue Shield Association and AHIP report found that the No Surprises Act has saved around 9 million patients from surprise medical bills since January of 2022.⁴ Interestingly, as people are beginning to fear devastating medical bills less, studies suggest the Act could also result in 3 million more emergency room visits each year. Additionally, the HHS reportedly received more than 90,000 claims since launching the independent dispute resolution portal in April. This substantial and skyrocketing growth clearly indicates that, at the very least, the No Surprises Act is benefitting patients who otherwise would not have received healthcare.

So how does this concern health plans and where does WLT come in?

As mentioned earlier, the Transparency in Coverage Rule and No Surprises Act seek to make information more available by giving consumers the tools they need to access pricing information. As the regulations require health plans to provide this information, this means that plans and issuers are on the clock to make this information available.

• For all plans beginning on or after January 1, 2023 – Plans and issuers must make cost-sharing information available for 500 items and services identified by the Department for plan years (in the individual market for policy years).
• For all plans beginning on or after January 1, 2024 – The same requirement imposed as of 1/1/23, but for ALL services, items, and prescription drugs.⁵

Additionally, employer-sponsored Group Health Plans and Health Plan Insurers are required to provide a self-service tool for enrollees to access personalized out-of-pocket cost estimates for potential pharmaceutical and medical care.⁶ This includes making the underlying negotiated rates for covered healthcare items and services and personalized out-of-pocket cost information available to participants and beneficiaries through an internet-based self-service tool.

All of these requirements are already a heavy lift to handle, but they only become more critical when taking the penalties for failing to comply into account. For plans and issuers that fail to comply with certain regulations, potential penalties include corrective actions or fines reaching up to $100 per member per day.

Keeping in compliance is only going to become more vital as more regulations come into effect. That’s why WLT’s advanced web portal, MediConnX^360™, powered by TALON, is here to help you stay ahead of the curve, with turnkey solutions that are compliant, comprehensive, and future-facing. MediConnX^360™’s leading-edge technology and services provide compliance solutions built for today and equipped to take on the future, including MyMedicalShopper™, a revolutionary healthcare comparison shopping platform that grants users the industry’s most exclusive capabilities:

• Industry’s leading real-time medical shopping tool
• Proprietary machine learning technology adds “secret sauce” to more than 3.7 billion annual medical claims in our massive data warehouse
• Comprehensive solutions that empower consumerism and reward employees for choosing lower-cost care
• Tools to identify over 41% of total medical cost as wasted spending
• The only platform demonstrated to the departments responsible for the development of the Transparency in Coverage Rule

 

As updates to the NSA and other healthcare regulations continue, WLT is committed to making sure you stay connected to the industry’s most comprehensive, compliant, and automated benefits administration solution, so you don’t fall behind.

With staying ahead of the curve in mind, MediConnX^360™ also allows employers to:

• Grant on-demand access of machine-readable files and reports to administrative and employer users
• Distribute information to a large audience using the integrated announcement feature
• Provide a communications tool to link employers, members, and others for such items as ID card requests, enrollment, secure messaging, and more

Simultaneously, MediConnX^360™ allows employees to:

• Verify claim payments
• Search physicians linking members with providers
• Manage enrollment, family status changes, and ID card requests

The No Surprises Act is here to stay, and the law is already shifting the way physicians and insurers approach healthcare. Compliance is more important than ever, not just to save people from surprise medical bills, but to make sure they’re on the right side when it comes to new regulations and updates. Surprises aren’t always fun, especially in the healthcare space. If you’re looking for a way to avoid those surprises, regulations such as the NSA, along with WLT’s MediConnX^360™, are your answer.

 

References:

1. https://www.cms.gov/newsroom/fact-sheets/no-surprises-understand-your-rights-against-surprise-medical-bills
2. https://www.kff.org/health-reform/issue-brief/no-surprises-act-implementation-what-to-expect-in-2022/
3. https://www.emoryhealthcare.org/patients-visitors/no-surprises-act-disclosures.html
4. https://www.beckersasc.com/asc-coding-billing-and-collections/no-surprises-act-in-2023-10-things-to-know.html
5. https://www.cms.gov/healthplan-price-transparency/plans-and-issuers
6. https://talonhealthtech.com/transparency-in-coverage-summary/#:~:text=Overview%20of%20Transparency%20in%20Coverage%20Final%20Rule&text=historical%20payments%20to%2C%20and%20billed,issuer%20at%20the%20pharmacy%20location