2022 brings new hope and new challenges for healthcare providers. Near the top of the list: the No Surprises Act, which took effect on January first of this year.
The No Surprises Act, which establishes new federal protections against “surprise” medical bills, is unequivocally good for patients. It ensures that consumers get the information they need to make informed choices, which improves the patient experience both before and after care. For providers, this will eventually be a positive thing, by creating opportunities to provide differentiated care and service. Getting there, however, is far from easy.
Hospitals now face the daunting task of connecting a myriad of affiliated and non-affiliated providers and communicating the sum of that information to patients in a clear and effective way. Patient access teams, already under-staffed and overburdened, must ensure compliance with rules and regulations that are difficult to understand and become experts in complex provider and payer relationships. Patient access and hospital leaders must do it all through a layer of ambiguity: is the No Surprises Act really in effect? When will CMS begin levying fines? Is compliance required for both parts of the two-part Act? The answers are unclear.
What we do know, despite this ambiguity, is that providers must start preparing and moving toward compliance. Whether the Act is enforced tomorrow or in six months, it still requires organizations to implement new paths to compliance.
3 steps to stronger compliance
One of the core requirements for complying with the No Surprises Act is being able to easily and accurately determine which providers are in and out of network, both for the facility and the ancillary providers who are involved in the patient’s care. The in/out of network provider identification is at the core of providing the detailed good faith estimates that the Act necessitates.
To determine network specificity of multiple providers, patient eligibility details, and create a good faith estimate efficiently and effectively, providers should focus on three components: education, processes, and technology.
Education
I recently participated in a No Surprises Act podcast with Leslie Pierce, who is the Senior Vice President of Revenue Cycle at Methodist Healthcare System. Leslie commented that to successfully comply with the No Surprises Act, we need to take something that’s developed at a PhD level and make it accessible and operational for individuals who may only have a high school diploma.
I think that speaks well to the challenges that patient access teams face, as well as the criticality of education. It is imperative to educate front-line staff about the new requirements as well as the complexities of the provider and payer relationships, especially considering the impact of ancillary providers in complying with the Act. We must help them understand what we’re complying with and why and put processes in place to continue that education and keep that knowledge fresh.
Processes
Speaking of processes, they will be essential to navigating the No Surprises Act. Providers need a reliable mechanism to identify in- and out-of-network patients, realizing that eligibility responses won’t be a silver bullet. Once provider-specific network determinations are made, leveraging those details to determine the appropriate consent, disclosure, notice, and estimate will be crucial.
The disclosures and notices posted by the CMS can be helpful here; instead of reinventing the wheel, utilize their guidelines to operationalize those processes. Processes are important to estimate forms and templates as well. Consider using multiple templates for uninsured, good-faith estimates, and insurance patient responsibility estimates.
Processes are particularly important for identifying out-of-network providers that may be a part of the patient’s care team, such as third-party affiliated providers that aren’t in network. This is essential for delivering good faith estimates and consolidating estimates across settings of care, both acute and ambulatory, so they include physician and hospital charges. It is also one of the most difficult pieces of the No Surprises Act puzzle: how to gather accurate estimates from affiliated providers and incorporate them into a patient-friendly format.
In addition, providers should implement processes that actively identify patients who access the system in less traditional ways. The No Surprises Act covers all patients, so organizations must be sure to find those who may otherwise slip through the cracks. This might look like a routine tracking mechanism that ensures all patient visits for a time period were screened, and acts as a safety net to prevent non-compliance and its associated fees.
Finally, consider your registration processes. Systems that enable pre-registration and self-scheduling give patients more control and convenience while giving providers a head start on identifying patients who may be subject to compliance. As a result, the patient experience improves, while patient access teams have more bandwidth to focus on the requirements of the new legislation.
Technology
If education tackles the who and why, and processes take care of the what, technology is the how. Put plainly, providers will have a difficult time complying with the No Surprises Act without a technology partner who actively incorporates many of the identification and compliance requirements into their solutions. The alternative is to manually manage compliance using people, which is a costly and less effective means of meeting the requirements of the Act.
Technology plays multiple roles in compliance. Integrated patient access solutions remove human error from the equation, prompting registration staff at each step of the intake process to ask the right questions, gather the appropriate information, and trigger the appropriate actions. Staff can train through usage, so teams gain the education they need to be successful. Technology solutions facilitate and streamline processes, ranging from identification of in- and out-of-network patients to creating estimates, automating the steps required to comply with the No Surprises Act.
Virtual intake solutions play a critical role in ease of compliance as well. In addition to enabling patients to pre-register ahead of time, on the device of their choice, digital solutions facilitate easier delivery and consumption of both patient responsibility and good faith estimates.
Some requirements will demand new technology innovations. Connecting the dots between hospitals, physicians, third-party providers, and payers is not a simple task, or one that many existing providers are readily prepared to confront. Look for a technology partner that understands the Act and has broad solutions that are equipped to meet compliance across a number of scenarios.
At PELITAS, we continue to evolve our relationships with data providers to refine eligibility responses. We also recognize the current limitations of eligibility responses and are actively pursuing alternative ways to identify in- and out-of-network patients and create more accurate good faith estimates.
2022 is sure to hold some surprises, including (ironically) how the No Surprises Act plays out. We may not know what the future holds, or what/when/if/how the CMS will enforce the Act, but we can prepare. By focusing on education, processes, and technology, healthcare providers can build a foundation for compliance while eliminating surprises for patients.
Author Bio:
Steven Huddleston is a seasoned revenue cycle executive and the President & CEO of PELITAS. In 2019 and 2020, PELITAS was named Best in KLAS for its patient access software and technology and currently maintains that position today. With more than 25 years of experience in provider healthcare, Steven has a proven record in leading organizations through periods of significant change, including: accelerating innovation and growth, integrating mergers and acquisitions, and building high-performing teams.
Prior to joining PELITAS, Steven helped build the investment thesis and identify the acquisitions to launch nThrive and was subsequently appointed President, Service Solutions & Chief Client Officer. Prior to nThrive, Steven was a Managing Director in Accenture’s Healthcare strategy practice, where he worked with not-for-profit provider organizations and private equity-backed portfolio companies to drive business transformation through operating strategy and model design, technology selection, and post-merger integration change management.
Steven spent 15 years with Hospital Corporation of America (HCA) in progressive financial and revenue cycle leadership roles. After leading revenue cycle operations at two shared service centers, he helped launch Parallon, a revenue cycle outsourcing subsidiary of HCA.
Since joining PELITAS in November 2018, he has positioned the company as the leader in patient access technology solutions to support hospitals and physicians by recruiting industry-leading talent, launching innovative solutions, and winning the Best in KLAS designation two years in a row.