The No Surprises Act (“Act”) for healthcare went into effect on January 1, 2022. There are several key provisions.
Most significantly, the “Self-Pay Rule” under the Act generally requires healthcare facilities and providers to:
- Post required notices concerning an “uninsured (self-pay)” patient’s right to obtain a good faith estimate at the provider’s offices and on its website.
- When a person seeks care, determine whether the patient is a self-pay patient.
- Inform self-pay patients orally and in writing that they have the right to obtain a good faith estimate of charges upon request or upon scheduling an appointment.
- Provide the required written good faith estimate to the self-pay patient within the time required, as follows:
- If the service is scheduled at least 3 business days in advance: not later than one 1 business day after the date of scheduling;
- If the service is scheduled at least 10 business days in advance: not later than 3 business days after the date of scheduling; or
- If a good faith estimate is requested by a self-pay patient, or if a patient inquires about the cost of care: not later than 3 business days after the date of the request.
The Self-Pay Rule requirements seem to apply only to self-pay patients who schedule their appointment at least 3 days in advance, and possibly to those who request an estimate in advance. However, in the case of a patient who schedules an appointment less than 3 business days in advance, the rules require the provider to provide the good faith estimate not later than 1 business day after the date of such scheduling. The rules also acknowledge that in the case of emergency care, a good faith estimate may not be required.
The main consequence for billing an amount in excess of the good faith estimate is that a patient may initiate a Selected Dispute Resolution process and likely avoid paying his or her full bill if the actual charges are more than $400 over the estimated charges. In addition to the Selected Dispute Resolution consequences, failure to comply with the No Surprises Act may subject the provider to additional adverse action by state or federal agencies. States have the primary responsibility for enforcing the No Surprises Act and related regulations; however, if a state fails to substantially enforce the requirements, the U.S. Department of Health and Human Services can impose a corrective action plan and/or monetary penalties of up to $10,000 per violation.
If you would like to discuss these or similar issues in more detail, please contact Jonathan M. Weis at (312) 368-0100 or firstname.lastname@example.org.