No Surprises Act:
The Not-So-Great Surprise

Patient Access is under attack.  Again. 

At least that is what it feels like to many leaders in this space.  The No Surprises Act (NSA), live as of January 1, 2022, has a noble purpose of reducing surprise billing to both commercially insured and uninsured patients.  This premise would lead you to assume that the bulk of the required changes and work effort would fall on the billing office.  This assumption misses the mark, considerably.

In recent years, there have been four significant points of legislation that have had a direct effect on Patient Access processes and workflows (two are specific to Maryland):

Each of these have created an operational burden to Patient Access, with the heaviest efforts driven by requirements from FFD and NSA.  Not only do they add cost to the workflow, but they duplicate efforts around producing estimates that are prohibited from being combined in any way. The impact of NSA reaches beyond Patient Access as well and burdens key departments who must gather, analyze and produce estimate information and reporting.

The penalty for non-compliance with the NSA is set at $10,000 per violation. CMS has committed to conducting a small number of audits in 2023, but the application of the penalty is currently unknown.  For example, if a provider fails to give notice during scheduling to a self-pay patient AND fails to send a GFE to that patient, does that constitute two violations for that patient and a combined $20,000 penalty?  If that logic is true, the financial cost of non-compliance can quickly exceed the roughly $1,000,000 fine recently imposed on a Georgia hospital for non-compliance with the Price Transparency laws.  Enforcement of the NSA has been light to date, but it is getting public, legislator and litigation attention.

With the looming penalty for non-compliance, one recent client (a multi-hospital health system and a large community physician group) asked i3 Healthcare Consulting (i3HCC) for help with implementing change to bring them into compliance. 

Interpret the Legislation (and get Legal advice)

The NSA legislation is broken into two parts and consists of roughly 400 pages of explanation of terms, requirements, and estimates on the expected costs to be incurred by the healthcare system across the United States.  There are also requests for feedback on included and proposed concepts, and notices that future rulemaking will add even more (potentially complicated) requirements.  i3HCC’s approach engages core client members early in the process to read and interpret the legislation, then design initial standard workflows around the requirements.  Once those discussions have been held, the real work begins to gain consensus on interpretation and ask for guidance from the client’s internal legal team/advisor where clarity and decisions are needed.

Mobilize a Large, Multi-Dimensional Implementation Team

The NSA legislation impacts nearly every point of Patient Access across the health system.  Specific teams are charged with addressing issues in the following categories:

  • Communication – Internal education on the NSA legislation is needed immediately.  We find that the requirements and the new terms are complicated enough that repeated educational sessions are necessary to help everyone understand and remember them. Additional sessions will be needed to understand the impact the requirements will have on specific department workflows.

    Communicating with patients requires the development of posters that contain all pertinent information required to be displayed in each Access area.  It also requires development of the good faith estimate that every self-pay patient should receive, along with appropriate disclosures.  Websites must be updated for all hospitals and a customer service unit will be organized and assigned for all patient questions related to NSA (and any other price-related questions).

  • Workflow – Even after constructing a proposed workflow, refinements and automation are necessary to enable compliance and allow for long-term process auditing.  As new anomalies are uncovered as a result of testing, further guidance from the legal team demands revision of the workflows to ensure compliance with the spirit of the new law.

    Surprisingly, we have found that even the electronic health record system vendors are unprepared for the rigors of this legislation and are slow to offer complete solutions. While we await their system revisions, the team can work on documenting the exceptions needing to be addressed.  One example of such an exception is a self-pay patient receiving psychiatric help as part of a specific program.  Although NSA states “all self-pay patients” must receive a GFE, the clinical leadership remains deeply concerned about patients avoiding services if conversations are held regarding cost prior to their visit.  These exceptions must be reviewed with the legal team and appropriate decisions are then documented and implemented.

  • Training – The Patient Access team members are, in large part, new to estimate production efforts.  The NSA demands that estimates are generated within 1 to 3 days of the scheduling effort, which put the burden squarely on the individuals scheduling services, especially in the professional clinics.  Training has to cover core concepts of the NSA legislation along with the new workflows, new system changes, and customer service training to teach staff how to talk with patients about estimated costs.  The training deployment strategy includes how to identify everyone who needs the training along with what type(s) of follow-up training will be needed.

    Specific training is provided to the Customer Service unit to address any new or unique questions they may receive.  This includes training on the complex dispute resolution process.

  • Infrastructure – Given the scope of this legislation and the impact from prior state and federal laws, a team should be assigned responsibility for long-term compliance with the NSA and preparedness should any future rulemaking require further changes.  We have found it takes a small health system team of estimate specialists to produce highly accurate estimates for the hospital-based services.  In one health system, core customer service unit was cross-trained to adeptly manage calls regarding questions related to both hospital and professional services.

  • Metrics – Measuring compliance with the workflow is challenging given the volume of locations that need to be monitored.  Measuring the accuracy of the estimates is critically important to understanding not only where risks of complaints may occur, but also where the internal team may need to revise and refine the logic behind their estimate methodology.

What Defined Success?

Success should be measured and monitored in a few very important ways:

  • GFEs being produced and sent in a consistent and accurate manner for all self-pay patients across the enterprise within the time limits required;

  • Notices posted in all 250+ registration / scheduling locations;

  • Websites updated for all 13 hospitals and the physician practices;

  • Exclusions documented and communicated to all affected team members;

  • Accuracy of GFEs being measured to be within the $400 thresholds;

  • Training provided to all 850+ team members and included in new hire training;

  • Customer Service metrics to monitor types and volume of calls;

  • Workflow tracking to monitor and measure the dispute resolution process; and

  • Billing hold work queues to review for possible balance billing conflicts.

What is Coming?

While implementation of the new workflows can be cumbersome and complex, there is deep concern around maintaining compliance with the new workflows over time.  Patients have expressed intense displeasure with receiving two estimates (one for NSA, one for FFD), having to listen to the plethora of disclosures while trying to schedule an appointment, and receiving all of the “new” paper that describes their rights for each program. Schedulers are the first to hear the patient’s displeasure, and most likely to veer away from following the established protocols to avoid irritating patients. If scrutiny is not placed on the compliance with these programs as a course of normal business, it will be easy to slip into a non-compliant status and potentially fail future audits.  With such steep penalties, this is of great concern.

The promise of future rulemaking around advanced explanation of benefits and truly holding providers accountable for the currently unenforced, Convening Provider components means that NSA legislation has the potential to have increasing impact on Patient Access operations.

Concerned about the status of your compliance with NSA Legislation, now and in the future?

Since 2021, i3HCC has been helping large complex health systems and community providers understand and achieve compliance and avoid risk of penalties. If you have questions or concern about NSA in your organization, please contact us through the link here: https://www.i3hcc.com/connectnewform to learn how i3HCC can help.

i3 Healthcare Consulting