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The No Surprises Act: Advanced EOBs on the Horizon

The No Surprises Act -- which is part of the Consolidated Appropriations Act introduced earlier this year -- is a pretty straightforward proposition: It is designed eliminate some of the surprises that group health plan participants encounter from unexpected charges. Health Affairs This Week Podcast provides a tidy summary of the act:

An initiative that affects revenue cycle needs further discussion : Advanced EOBs.

What is an Advanced EOB?

As reported on the JDSupra site in collaboration with Holland & Hart, a Law Firm with expertise in healthcare law:

Beginning in plan years that start on or after January 1, 2022 group health plans are required to provide, upon request, what the No Surprises Act refers to as an Advanced EOB. This new form is required to provide information on the estimated costs of procedures and services, especially the additional costs of non-participating providers. The request for an Advanced EOB may be made by the participant or their representative and must include the billing and diagnostic codes for the anticipated services. The Advanced EOB must then be provided within one business day of request for scheduled procedures (three business days if the request is made at least 10 business days before the scheduled procedure).

 Depiction of a paper EOB.

Reinhart Boerner Van Deuren, a law firm that maintains a dedicated Health Care Practice that spans the entire continuum of patient care and runs the gamut of complex legal issues, provides details of what must be included in an Advanced EOB:

  • Whether the provider or facility is in- or out-of-network;
  • If in-network, the contracted rate for the item or service;
  • If out-of-network, a description of where to find information on in-network providers and facilities;
  • The billed amount estimate from the provider or facility;
  • An estimate of the amount the plan will pay;
  • An estimate of the person’s cost-sharing responsibility for the item or service, as of the date of the notice;
  • An estimate of the amount the person has incurred toward their cost-sharing limits, including deductibles and out-of-pocket maximums, as of the date of the notice;
  • Whether the item or service is subject to medical management, including concurrent review, prior authorization, or step-therapy or fail-first protocols;
  • A disclaimer that the advance cost estimate is only an estimate; and
  • Any other information or disclaimers that are appropriate and consistent with the above.

Taking the Necessary Steps for Advanced EOBs

As mentioned in the podcast, the No Surprise Act is taking shape at rapid speed. Healthcare providers and RCM Outsourcers must take a proactive approach to get ahead of the changes, or be out of compliance. The JDSupra site provides the following recommendations for plan sponsors:

  • Amend Summary Plan Descriptions to include a description of the right to request an Advanced EOB and the steps needed to do so;
  • Ask insurers/TPAs what steps they are taking to get ready for Advanced EOB requirements; and
  • Review service provider agreements and revise as necessary to include responsibility for providing Advanced EOBs (and responsibility for any penalties and/or costs that may be associated with missing deadlines or providing egregiously incorrect information).
Doctor meeting reduced

The No Surprises Act could have very profound implications from data collection, analysis, audit, and compliance standpoints. Revenue cycle must take the proper steps to ensure adherence to the new standards, while also continuing to maintain its operations. They key will be ensuring that all information is electronified to ensure minimal disruption to operations. OrboGraph is, of course, diligently monitoring the news and will continue to provide updates on implications and impacts for our clients and partners.

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