The American Counseling Association’s January town hall focused on the No Surprises Act, which aims to increase transparency in medical costs and protect clients from “surprise” medical bills caused by out-of-network care. Catherine Brandon, a partner at ACA’s lobbying firm Arnold & Porter, discussed three main requirements of this act, which went into effect on January 1:
- Prohibiting balance billing or surprise billing (i.e., when a health care provider bills a patient for the difference between the amount the provider charges and the amount the insurance pays) for out-of-network providers in an in-network facility
- Requiring a good faith estimate (GFE) of expected costs before scheduled services for uninsured and self-pay clients
- Ensuring continuity of care and accuracy of provider directories
Sometimes people carefully select an in-network hospital and medical provider only to discover their medical bill is much higher than they expected because they unknowingly received medical care from an out-of-network provider during their stay. This balanced billing requirement aims to prevent that potential sticker shock by prohibiting providers who are out-of-network with a client’s insurance from charging more than their in-network costs when clients receive care at the in-network facility.
This aspect of the act will probably not apply to most private practitioners, Brandon noted during the town hall held on January 19, only those providing services outside their private practice at in-network facilities. So, if a counselor works at a hospital or performs telebehavioral services while a client is staying in a hospital, for example, then they could only charge the client at the in-network rate, not the out-of-network rate.
Although the act does not dictate the out-of-network payment amount between the insurer and provider, it did establish an informal dispute resolution process to oversee any potential disputes on payment.
One of the key provisions affecting counselors is the requirement to provide a GFE to uninsured and self-pay clients before services are rendered. It is the responsibility of the provider to ask clients if they will file a claim with their insurance to know if this rule applies to them, Brandon said.
The GFE should include a clear description of provided services, including diagnostic and expected services codes, and the expected charges associated with each service. Assigning a diagnosis code before seeing a client could pose a problem and ethical issue, but ACA suggests using a general diagnosis code such as “no diagnosis” before the first session, and then counselors can issue a revised GFE after the intake assessment.
The Centers for Medicare & Medicaid Services has a Good Faith Estimate template form that counselors can use to ensure they include all the appropriate information.
The time frame requirements for issuing the GFE are as follows:
- No later than one business day after the date of a scheduled appointment that is three to nine business days away.
- No later than three business days after the date of a scheduled appointment that is 10 or more business days away.
- No later than three business days after the date of requested services without a scheduled appointment. (Another GFE must be provided within these time frames if the client decides to schedule an appointment.)
Counselors can provide clients with a single GFE for recurring services (such as ongoing counseling visits), which is good for one year. But if the information, including costs, services needed or billing codes, changes at any point, then providers must issue a new GFE no later than one business day before the next scheduled appointment.
The GFE is just an estimate; it is not legally binding and may change at any point. However, if the actual charge is more than $400 above the estimate, the client has the right to dispute the charge through the new patient-provider dispute resolution process.
In addition to orally telling clients about the availability of the GFE, counselors should include a notice on their website, in their office and on-site where scheduling or questions about costs occur. And counselors should retain a copy of the GFE with the client’s record for six years.
Continuity of care and provider directories
If a counselor’s contractual relationship with a client’s insurance ends (i.e., they are no longer in network with the insurer), they must continue to accept the in-network rate for 90 days after the health plan or issuer notifies the client of the change in network status. This provision only applies to continuing care clients, Brandon noted, which include those undergoing treatment for a “serious and complex condition” — one that is “life-threatening, degenerative, potentially disabling or congenital” and requires “specialized medical care over a prolonged period of time” or that is “serious enough to require specialized medical treatment to avoid the reasonable possibility of death or permanent harm.”
This law also stipulates that health care providers who have a contractual relationship with an insurer must submit up-to-date provider directory information to the insurer. And providers must reimburse insured clients who inadvertently relied on an incorrect provider directory and received out-of-network care or paid more than the in-network sharing amount. Counselors could protect themselves and shift the liability to the insurer, Brandon said, by stating it’s the insurer’s responsibility to maintain an updated directory in their contract with the insurer.
The U.S. Department of Health and Human Services has not yet issued regulations that would further explain and define these requirements. This means there is currently not much guidance on these regulations.
Watch the full video of the town hall on the No Surprises Act at ACA’s YouTube page: https://www.youtube.com/watch?v=gy3H3col07U
Learn more about the No Surprises Act and these specific provisions from the following resources:
- Centers for Medicare & Medicaid Services webpage: https://www.cms.gov/nosurprises
- Centers for Medicare & Medicaid Services’ training presentation for providers: https://www.cms.gov/files/document/a274577-1b-training-2nsa-disclosure-continuity-care-directoriesfinal-508.pdf
- ACA’s frequently asked questions regarding the act: https://www.counseling.org/docs/default-source/resources-for-counselors/nosurprisesact-faqsseries.pdf?sfvrsn=5ee92c2c_2
Lindsey Phillips is the senior editor for Counseling Today. Contact her at firstname.lastname@example.org.
Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.