Your Rights and Protections Against Surprise Medical Bills: No Surprises Act
New federal regulations implementing the No Surprises Act (enacted by Congress in 2020) went into effect on January 1, 2022. This law aims to protect consumers from unanticipated medical bills. There are three (3) parts to the regulations that multiple federal agencies, including the U.S. Department of Health and Human Services (HHS), developed: Part ll applies to Children’s Square – requires all health care providers (including LISW, LMHP, and ARNP) and health care facilities licensed, certified, or approved by the state to provide good faith estimates (GFEs) of expected charges for services and items offered to uninsured (e.g., not enrolled in any health plan) and self-pay (e.g., not planning to file a claim with their plan) consumers. Effective January 1, 2022, any health care provider or health care facility subject to state licensure must provide a GFE of expected charges for services and items within specific timeframes to current/established and future patients. These new regulations set forth specific requirements for how providers must inform patients of their right to a GFE, what these good faith estimates must contain and how records are to be maintained. The regulations also establish a process for consumers to dispute provider charges that “substantially exceed” a good faith estimate. (The language defines “Substantial” as $400 or more). Patients enrolled in federal health insurance plans (e.g., Medicare, Medicaid, TRICARE, Indian Health Service, or the Veterans Affairs health system) do not require a GFES.
What is “balance billing” (sometimes called “surprise billing”)? When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as copayment, coinsurance, and/or a deductible. In addition, you may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network. “Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the total amount charged for a service. This practice is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit. “Surprise billing” is an unexpected balance bill. This situation can happen when you can’t control who is involved in your care-like when you have an emergency or when you schedule a visit at an in-network facility but unexpectedly receive treatment from an out-of-network provider. The chances of this happening at Children’s Square are low; however, we are posting these rights to inform all clients of their rights.
For clients at Children’s Square who are out of network and/or private pay, your provider will complete a GFE-good faith estimate in collaboration with the client. In addition, we will do the following for compliance with this new federal rule:
Ask both current/established and new patients if they have any health insurance coverage and ascertain if they are uninsured or self-pay. If a patient is insured, we will ask to make a copy of the client’s insurance card for our files and ask the patient if they plan to submit a claim for the services provided by Children’s Square.
Inform all uninsured and self-pay patients of their right to a GFE. Written notice must be provided in clear language that the individual can understand in an accessible format, prominently displayed in the office and on the provider/facility’s website, and easily searchable from a public search engine. In addition, written notices should account for vision, hearing or language limitations, including those with limited English proficiency or other literacy needs.
The written notice may be provided on paper or electronically, depending on the individual’s preference. Children’s Square will share the information with the client orally when they schedule services or when the patient asks about costs.
Clients are entitled to receive this Good Faith Estimate (GFE) of what the charges could be for therapeutic and/or psychiatric services provided to them. This Good Faith Estimate does not serve as a recommendation for treatment or a prediction that you may need to attend a specified number of visits. The number of appropriate visits for each client and the estimated cost for those services depend on individual needs and and what they agree to in consultation with their Children’s Square therapist and/or psychiatrist. Clients are entitled to disagree with any recommendations concerning their treatment, and you may discontinue treatment at any time. We encourage all clients to speak with their provider at any time about any questions they may have regarding their treatment plan, or the information provided to them in a Good Faith Estimate.
Children’s Square will also alert the patient if their provider does not participate in-network; provide an estimate of the out-of-network charges with the GFE; and list in-network providers at our facilities. The No Surprises Act requires that by 2022, plans verify and update their provider directories at least every 90 days. In addition, in-network providers must submit to plans the following information: *When the provider begins a network agreement with a plan; *When the provider terminates an agreement.
Patient Continuity of Care Health plans will be required to notify patients of any changes to the in-network status of current treating providers and ensure continuity of care. If a provider contract is terminated, a patient can elect to continue with that provider for either 90 days after the contract or the date when no longer a continuing patient, whichever is earliest. The provider is required to continue the provision of services under the same terms and conditions as the in-network contract unless the provider is terminated for cause (such as failing to meet quality standards). This provision allows patients time to transition their care to an in-network provider, so there is no abrupt termination of services.
This information will be posted on our website and published in our offices.
You may start a dispute resolution process with the U.S. Depart. of Health and Human Services (HHS) if you disagree with the GFE and cannot resolve it with your provider. If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill. Clients have the right to initiate a dispute resolution process if the amount charged for services substantially exceeds the estimated charges stated in your Good Faith Estimate (which means $400 or more beyond the estimated charges).
If you have questions or believe you are being billed incorrectly, you may contact the U.S. Department of Health and Human Services (HHS) at 318-626-0986. To learn more about your rights under federal law, go to https://www.cms.gov/nosurprises or call 1-800-985-3059.