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The No Surprises Act was effective Jan. 1, 2022, although the federal departments responsible for implementing the law have announced that they will not enforce certain portions of the law until they have issued all necessary regulations, and in some instances, until they have given stakeholders more time to acclimate to the new law.
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Implementing the No Surprises Act
The No Surprises Act of 2020 legislation became effective Jan. 1. It prevents patients from getting surprise medical bills for emergency and nonemergency services.
Transparency in patient billing and charges is a vital component in the practice of medicine. Collecting a payment, particularly when it is an unknown charge to the patient, is uncomfortable and for some practices has resulted in patients seeking eye care elsewhere.
The No Surprises Act rules apply to:
- Self-paying patients or commercially insured patients who choose not to use their benefits who receives bills for substantially more than they expected
- An insured patient who receives an unexpected bill from an out-of-network provider or facility for certain emergency or nonemergency services
Note: No Surprises Act does not apply to beneficiaries or enrollees in federal programs such as Medicare, Medicaid, Veterans Administration, Indian Healthcare Services or TRICARE. These programs have other protections against surprise medical bills.
Providing the Good Faith Estimate
Post the U.S. Department of Health and Human Services (HHS) form (PDF) on your practice website and onsite where scheduling or questions about the cost of services occur. The information must be prominently displayed and published in accessible formats and presumably available in languages spoken by patients.
Disputes
- A patient may dispute charge exceeding the estimate by $400.
- The practice has 10 business days to provide a copy of the disputed estimate and bill plus any documentation showing that the difference was based on a medically necessary service that could not have been reasonably anticipated when the estimate was initially provided.
- The practice should suspend collections and accrual of late fees, if applicable.
- The practice must not take or threaten any retributive action.
- The practice and the patient may agree to settle the dispute at any point.
Action Steps for implementation
When scheduling patients:
- Confirm participation status with your patients' insurance or confirm patients are paying their own bills.
- Explain the potential range of charges from a script prepared internally so that all patients receive the same message.
- Inform patients that they will be asked to sign a consent form agreeing to the form ahead of time to reduce front desk time on arrival.
- Explain that payment in full will be expected at the conclusion of the visit.
On the day of the appointment:
At check-in:
- Ask for the signed form copy if provided prior to the visit. Otherwise:
- Review the form and potential charges and obtain patient signature.
- Explain that payment in full will be expected at the conclusion of the visit.
At checkout:
- Collect payment in full and provide the patient with a copy of the bill.
Clinical examples
Scenarios like these occur every day in ophthalmic practices. When examining patients who are paying bills themselves or are out-of-network, be prepared to implement No Surprises Act billing protocol.
| Scenario |
Protocol |
Nonemergency care
An out-of-network ophthalmologist treats a patient covered by commercial coverage at in-network facility. |
The ophthalmologist may collect only the in-network cost-sharing from the patient and may not balance bill, unless the ophthalmologist has furnished an advance note to the patient and obtained the patient’s written consent to balance bill. |
The ophthalmologist was called to the emergency department. Care was provided and follow-up recommended in two days at the ophthalmologist’s office. The ophthalmologist is nonparticipating with the patient’s commercial insurance.
Most payers will pay for an out-of-network physician for emergency department visits. |
Post-Stabilization
If the same physician who cared for the patient in the emergency department saw the patient in their office shortly after the emergency room visit then the follow-up could be part of the post stabilization as it is the same physician who was out of network in the emergency setting.
However, if it is a different doctor seeing the patient on a subsequent day following the emergency visit is less likely to be considered part of the post-stabilization process. |
The ophthalmologist on call to the emergency department examined and cared for the patient.
The patient is referred to a retina specialist for follow-up. What if the retina specialist is an out-of-network physician? |
It's likely that the visit to the retina physician may be too far removed from the initial ED visit to qualify as post-stabilization.
If out-of-network, retina specialist must implement no surprises billing protocol. |
Additional Resources
Ending Surprise Medical Bills
The Centers for Medicare & Medicaid Services (CMS) provide an overview of the No Surprises Act.
What Physicians Need to Know About the No Surprises Act
In this episode of Moving Medicine, a video and podcast series produced by the American Medical Association (AMA), Todd Unger, AMA chief experience officer, discusses the No Surprises Act and what it means for patients and physicians with Emily Carroll, JD, a senior legislative attorney for the AMA's Advocacy Resource Center.
Preparing for Implementation of the No Surprises Act (PDF)
This AMA toolkit focuses on three operational challenges that physicians will need to address immediately in order to be compliant with the new requirements.
CMS: Frequently Asked Questions for Providers About the No Surprises Act (PDF)