Q&A on No Surprises Act: Learn about out-of-network services

Novita Management has all the details about the No Surprises Act. We first looked at Good Faith Estimates. Our experts are now digging deeper into the NSA’s application to out-of-network service scenarios.

We answer questions from providers like you. This helps to clarify confusion and keep your company in compliance.

It is not as simple as it seems to manage out-of-network service. Providers can feel confused in difficult situations. Fortunately, the No Surprises Act can be applied to complex, outside-of-network problems. This will help you stay prepared.

If you have any questions about the No Surprises Act, please consult your legal team, compliance division, or trade association.

Is the No Surprises Act applicable if a patient is treated at an in-network facility, but the providers are not?

Yes, the No Surprises Act applies if the hospital or facility is in-network, but any professional providers are not.

CMS has a document that explains how to bill for balances. For more information about your specific situation, contact CMS directly at provider_enforcement@cms.hhs.gov.

What if an out-of-network provider asks every patient to sign a multipage waiver all bases are covered

The provider waiver is not available to all patients. It cannot be obtained from certain professional services. This applies to services provided by anesthesiologists and pathologists, radiologists and neonatologists, hospitalists, intensivists, hospitalists, and hospitalists.

CMS states that a patient or an authorized representative is not required to sign the consent form. The patient should understand or agree to pay out-of-pocket for balance bills on services outside their network.

Balance billing may not be allowed in certain circumstances, even if the patient has signed a waiver. For more information, refer to CMS documentation or contact CMS directly at provider_enforcement@cms.hhs.gov.

Are providers allowed to continue charging out-of-network fees for services that have been scheduled in advance?

Yes, provided that the out-of-network notice and consent are signed and delivered for services not urgent. This CMS document provides more details.

We don’t want to balance billing our patients outside of our network. We could not engage in this practice and still comply with NSA.

Requirements will not apply if:

  • Providers have a policy of writing off balances if they process a non-emergent claim that is not in the network and the patient does not receive a bill. The provider would not have exposure to the patient, and the patient would not file a complaint.
  • The provider posts adjustments according to the payer’s remit for out-of-network or emergent cases. The provider is not exposed to this situation.

Please consult your legal team and contact CMS at provider_enforcement@cms.hhs.gov for official confirmation of what is best for your organization.

Are provider NPIs or tax IDs used to identify services, not in the network or within-network?

In general, NPI is used to identify out-of-network services.

Is it necessary for a provider to file with insurance if they are out of network and the patient has out-of-network benefits?

Balance billing is not allowed for patients.

  • Services for emergencies. If a patient requires emergency services from an outside-of-network provider or facility, the maximum amount that the provider or facility can bill is the plan’s cost-sharing amount. This includes copayments or coinsurance. This covers services required to stabilize the patient’s condition unless the patient consents in writing and waives any protections that might not be balanced billed for these services.
  • Some services are available at an in-network hospital, ambulatory surgery center or hospital. Certain providers may not be in the network when a patient is receiving services at an in-network hospital. These providers can bill the maximum amount allowed by the plan’s cost-sharing amount. This includes emergency medicine, radiology, pathology and laboratory. If the patient waives their protections, these providers cannot balance bill you.

Please refer to the CMS documentation for more information on balance billing protections and the model disclosure notices concerning patient protections from surprise billing.

Prepare for services outside of your network.

Knowledge is power. Be prepared for any out-of-network situations that might throw you off. These insights will help you ensure compliance with the No Surprises Act and out-of-network situations.

Contact your legal team, compliance office, or trade association if you have any questions or concerns. You can also get specific information about your organization’s situation by contacting CMS directly at provider_enforcement@cms.hhs.gov.