By J’NON GRIFFIN
RN, MHA, HCS-D, HCS-H, HCS-C, HCS-O, COS-C
Sr. Vice President of Compliance & Coding
Has a complaint been lodged against your behavioral health organization under the No Surprises Act (NSA)?
In a new report, the Centers for Medicare and Medicaid Services (CMS) said it has received some 12,000 complaints related to alleged violations of the NSA, with approximately $4 million in relief paid to consumers and providers after investigations.
Total restitution reported from closed complaint investigations as of June 2024 totaled $4,183,383, according to the August 2024 CMS Complaint Data and Enforcement Report.
The CMS report includes all complaints and investigations. While the report does not provide specific information about individual reports, it does break down the numbers to show how many complaints were specifically NSA-related.
Of the total 16,073 complaints received by CMS, 12,077 were NSA-related complaints.
Complaints regarding Good Faith Estimates required under the NSA – an aspect of the legislation likely to affect behavioral health providers -- were among the most common complaints lodged in the NSA-related category. A total of 1,922 complaints regarding Good Faith Estimates were reported.
What is the No Surprises Act?
The NSA was enacted as part of the Consolidated Appropriations Act of 2021 (H.R. 133; Division BB – Private Health Insurance and Public Health Provisions), and became effective in 2022. The NSA is designed to protect patients from surprise medical bills resulting from emergency medical care, ambulance services, and certain services received from out-of-network providers at in-network facilities.
Although psychologists, therapists, and behavioral healthcare providers generally do not offer the types of services the NSA was specifically designed to address, they are affected by NSA’s requirements to give patients clear information about costs before care is provided.
What is the Good Faith Estimate under No Surprises?
Under the NSA, healthcare providers and facilities operating under the scope of a state-issued license or certification must share a specific consent document and provide a Good Faith Billing Estimate prior to beginning care.
Providers must give every new or continuing client an itemized estimate of medical costs (including facility fees), upon request or after the service is scheduled. This requirement applies to people who don’t have health insurance as well as those who plan to self-pay rather than submit a claim to an insurance plan. Every uninsured or self-pay client must also be informed about their right to receive a Good Faith Estimate.
As with so many other regulations pertaining to healthcare, there may be some slight variations in surprise billing requirements from state to state because some states already had surprise billing laws in effect before the NSA was enacted. The Act supplements existing laws. It does not supplant any state laws, but establishes a “floor” for billing transparency and consumer protections.
What behavioral healthcare providers should do
Court challenges halted some of the provisions originally intended under the NSA, and CMS has continued to clarify expectations through rule-making and additional guidance since the NSA took effect.
It's important for behavioral healthcare providers to fully comply with all updated NSA requirements. The number of NSA-related complaints CMS has seen is significant, and it is highly likely that the number of complaints will increase as consumers become more knowledgeable about their rights to advance billing information. Will your organization be prepared?
SimiTree offers a white paper explaining the NSA in detail and featuring best practices for providing Good Faith Estimates to clients and patients. Download it here at no cost.
How SimiTree can help
Our compliance experts work with behavioral health providers to ensure full compliance with all federal rules and regulations, including the No Surprises Act. We provide staff training, help set up professional web sites compliant for disclosure requirements, review the dispute resolution process for uninsured or self-pay consumers, and make certain our clients receive the knowledge, training, and full support required for success.
SimiTree’s analytics and compliance experts go the extra mile for clients, showing organizations how to build improvements into data-collecting processes, streamline workflow, implement tracking controls, and make use of standardized screening tools and assessments.
With a full complement of outsourced coding, billing, revenue management, and compliance services, SimiTree offers the solutions your organization needs to ensure the highest level of accuracy and performance day in and day out.
Reach out to us today, and let’s work together to shore up compliance and improve performance at your organization.
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Rapidly changing regulations are impacting all behavioral health providers, and creating many areas of uncertainty for providers. We want to address the questions that matter most to you each week.
Ask your compliance questions – or request the specific topic you’d like more information about – by writing to me at jgriffin@simitreehc.com to let me know what you’d like to read about in a future Compliance Report.
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J’non Griffin serves as Senior Vice President/Principal for the Compliance as well as Coding divisions at SimiTree. Her healthcare career spans three decades of clinical and leadership experience, and she has a track record of helping many provider types implement effective compliance programs. She is a certified ACHC and CHAP consultant and holds additional certifications in diagnosis coding and other healthcare specialties. As an AHIMA ambassador, she was instrumental in the implementation of ICD-10.