The No Surprises Act was passed by Congress in December 2020. The purpose of the Act is to protect patients from surprise medical bills and prohibits balance billing of patients for certain out-of-network care. Healthcare payers and providers will have until January 1, 2022, to update their processes to comply with the new rules and regulations.

The Act will “require extensive planning to ensure the infrastructure is in place to support both the payer and provider requirements for 2022,” said Matthew Albright, Chief Legislative Affairs Officer at Zelis. “For payers, top of mind is regulatory compliance with a real focus on solutions that will drive down that administrative burden of the legislation, while also supporting dispute resolution and claim cost management.”

Over the following months, healthcare payers will need to analyze the Act’s requirements to develop their pricing strategy. “Pricing, identifying qualified claims, managing the provider dispute process, and effective clean settlement are all going to require significant resources, coordination nation, and planning in advance of 2022,” said Albright.

According to the legislation, payers must:

• Establish a verification process in which the payer verifies and updates provider directory information “not less frequently than once every 90 days.”
  • The verification process must have a process for removal of a provider if the payer is unable to verify info “during a period specified by” the payer.
  • Information to be verified includes: name, address, specialty, telephone number, and digital contact information.
• Establish response protocol for members who request information on whether a provider is in-network.
  • Via telephone call and electronic, web-based, or internet-based means
• Maintain directory database on a public website + dated print directory.

Payers are also responsible for updating patient insurance ID cards, both physical and electronic, to include the deductible, Out of Pocket maximum limit, telephone number and website address for consumer assistance, and information on in-network providers. Some payers are devising ways, such as QR codes, to fit more information on one card while remaining compliant with the requirements. Additionally, a price comparison tool on the payer’s plan website is also required. This tool will help patients compare the cost-sharing for specific items or services by specific providers concerning the plan year, geographic region, and participating providers.

Healthcare payers need to consider these new Act requirements when planning over the next year. Albright suggests that the organization asks itself, “how are you going to achieve market alignment with your pricing strategy? How will members be supported? What will they do if they get a balanced bill? How will your existing partners add value and support your compliance?” to prepare for the transition into 2022.

To learn more about how to get in compliance with the No Surprises Act, click here.