What the No Surprises Act Means for the Healthcare Community
- SolvEdge
- Feb 03, 2025
- 6 mins read
The No Surprises Act came into effect from January 2022. The Consolidated Appropriations Act of 2021 had the No Surprises Act as part of the bill to protect patients and improve directory information accuracy. This law announced a new set of guidelines for health insurance issuers that offer group or individual health insurance coverage to mandate the following.
- A provider data verification process to ensure accurate provider directories
- A response mechanism for people inquiring about the network status of a provider
- A publicly accessible database that has the exact information about their innetwork providers and facilities
The new law does not pre-empt any of the existing state laws and will not apply to stand-alone dental care plans. Also, Providers and facilities need to communicate changes about their provider directory information to health plans and insurers within a specific time period. The collective goal is to have Insurers and providers work cohesively in order to improve the provider information accuracies in public-facing directories and other relevant materials
| Hard-hitting Facts You Need to Know Right Now! | ||
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What is a Surprise Medical Bill? A Surprise medical bill occurs when an insured patient receives care at an in-network facility, however providers who treat the patient are not in the patient’s insurance network. Surprise medical bill can also occur when an insured patient receives emergency care at an out-of-network facility. |
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1 in 5Americans has received a surprise medical bill from an emergency department visit |
2 of 3Americans say they are concerned about the affordability of unexpected medical bills and nearly half of them can’t afford to pay surprise bills in full |
Introducing
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| Source: Kaiser Family Foundation | ||
Why do Inaccurate Provider Directories occur in the first place?
- Providers Listed at Different Locations for Claims Management. This is not accurate information on which providers are available at each location and accepting new patients.
- Requirements for Compliance Requirements Changes. This makes it even more complex for different teams to be aligned.
- Data Management and Legacy Infrastructure. Siloed organizational structure makes it difficult for different teams to exchange data efficiently.
- User Adoption. Change in team structure and personal responsibilities make it a challenge
- Providers don’t Have Equal Stakes in the Game. Medicare Advantage Plans works in a way that the provider directory maintenance responsibilities have fallen on the health plans.
Consumer-facing Obstacles
Healthcare consumers are most likely to bear the brunt of these complexities involved in provider directory misinformation.
- Providers do not always practice at the listed location
- Phone numbers have changed and are not correct
- Providers are listed as in-network by mistake
- Providers who accept new patients not listed correctly
New Requirements: What You Need to Know
- Insurance plans need to follow a procedure for eliminating providers and facilities from the directory if information cannot be verified within a specific timeframe.
- Plans need to have a stringent process in place to verify and update provider directory database at least once every quarter, for providers and health care facilities in the available database.
- Plans need to update the provider directory within two working days of receiving a provider notification once their information has changed. This should include the elimination of provider names who don’t belong to the network anymore.
- Plans also need to notify within one working day if a provider or facility is in network to consumers who inquire about that provider or facility’s network status. This data is mandatory.
How Providers Can Optimize Efficiencies
Improve Data Accessibility Across the Organization. Care providers need to implement new solutions that make data exchange and accessibility simple across the organization. Hospitals can consider integrating automation solutions to enhance efficiencies and improve data accuracies. Hospitals use next-gen technologies and strategies to gather high-value patient data. Patient Reported Outcomes (PRO), Patient Generated Health Data (PGHD), Social Determinants of Health (SDOH) and other data are seamlessly gathered to deliver personalized recommendations and timely interventions. These strategies need to be used in insurance data in order to improve team efficiencies and data accuracies to mitigate the impact of Surprise billing.
To learn more about optimizing your billing processes and accelerating your revenue cycle performance, give us a shout!
