Recent legislation means changes on the horizon. Be prepared

Included in the 2021 Consolidated Appropriations Act, passed by Congress in December, is the No Surprises Act that goes into effect January 2022. The No Surprises Act, according to the FTC, “seeks to protect consumers from surprise medical bills arising out of certain out-of-network emergency care.”

BACKGROUND ON BALANCE BILLING

First, it is important to understand the three levels of insurance participation: participating provider, non-participating provider and non provider.

Next, we need to understand the definition of balance billing. Balance billing is when you bill a patient for the difference between what the insurance pays you and what your usual and customary fee is. Deductibles and coinsurance payments are not considered balance billing.

Medicare has, for many years, prohibited balance billing by participating providers. Medicare allows balance billing by non-participating providers of up to 15% over the Medicare fee schedule. (Of note, some states regulate this further.) Non-providers can balance bill, charging whatever fees they establish for their practice. Find more information on this at bit.ly/CMSbalancebilling .

PRACTICAL IMPLICATIONS?

As you read through the legislation, which can be found at congress.gov/116/bills/hr133/BILLS-116hr133enr.pdf beginning on p.1576, it is clear that the goal is to be certain patients are notified of their fees before they are seen by any provider so that they have no surprise bills after the visit. There are occasions where some commercial insurances providers are permitted to balance bill patients (if their contract allows) as long as they get written consent from the patient before the service is provided.

Some states have already passed their own legislation regarding this law, the details of which you can find via nonprofit The Commonwealth Fund at bit.ly/CommonwealthFundBalanceBills , that may be more restrictive than the federal legislation.

ACTION STEPS?

So what should you do?

1. Regardless of the insurance plan, be certain to notify the patient of fees before services are provided.
2. If your state and your insurance contracts allow you to charge usual and customary or balance bill your patient, be certain to obtain written consent from your patient.
3. Read all insurance contracts to ensure your compliance.
4. Watch for changes from your insurance plan as January 2022 draws near.

BE TRANSPARENT

Transparency in billing is always a good thing for the practice. Letting patients know what to expect and preventing billing surprises sets a patient’s mind at ease and helps to eliminate any uncomfortable encounters between patients and providers at the end of the visit. Watch for more on the No Surprises Act legislation as we move forward. OM

DR. JASPER practices in West Palm Beach, Fla.. She is an American Academy of Optometry fellow and is chief optometric editor of Optometric Management. Email her at april.jasper@pentavisionmedia.com.