No Surprises Act

No Surprises Act: Information on New Billing Disclosures Going into Effect in 2022

In December 2021, Congress passed, and the President signed, the No Surprises Act. This new law took effect January 1, 2022, establishes new disclosure requirements against surprise medical billing.

The No Surprises Act requires healthcare providers and facilities to provide Good Faith Estimates to uninsured, out-of-network, or self-paying clients for services offered when scheduling care or when the client requests an estimate.

Based on the information TLPCA has received after consulting our national organization and other sources, it appears that LPCs would be considered “health care providers” under this new law.

The new law requires that health care providers offer good faith estimates for services to any clients who are uninsured or not planning to use their insurance benefits to pay for services.

Good faith estimates should include:

1. Client’s name and date of birth;
2. A clear description of the primary item or service and, if applicable, the date the primary item or service is scheduled;
3. Itemized list of items or services, grouped by each provider or facility, reasonably expected to be provided for the primary item or service, and items or services reasonably expected to be furnished in conjunction with the primary item or service, for that period of care;
4. Applicable diagnosis codes, expected service codes and expected charges associated with each listed item or service;
5. Name, NPI and TIN of each provider or facility represented in the Good Faith Estimate, and the state(s) and office or facility location(s) where the items or services are expected to be furnished by such provider or facility;
6. List of items or services that the convening provider or convening facility anticipates will require separate scheduling and that are expected to occur before or following the expected period of care for the primary item or service;
7. Disclaimers that there may be additional items or services the convening provider/facility recommends that must be scheduled or requested separately;
8. Must state that the information provided in the Good Faith Estimate is only an estimate of items or services reasonably expected to be furnished at the time the Good Faith Estimate is and that actual charges may differ;
9. Must state that the client has the right to initiate the client-provider dispute resolution process if the actual billed charges are substantially in excess of the expected charges included in the Good Faith Estimate; and
10. Must state that the Good Faith Estimate is not a contract and does not require the uninsured or self-pay individual to obtain the items or services from any of the providers or facilities identified in the Good Faith Estimate.

The Centers for Medicare and Medicaid Services has provided a Good Faith Estimate for Health Care Items and Services template.

TLPCA strongly encourages any provider to consult with an attorney or compliance department in order to ensure compliance with the new requirements.

Below are forms provided by Centers for Medicare and Medicaid Services:

• CMS-10780 Appendix I – Model Disclosure Notice Regarding Patient Protections Against Surprise Billing
• CMS-10780 Appendix II – Standard Notice and Consent
• CMS-10780 Appendix III – Model Disclosure Notice Regarding Patient Protections Against Surprise Billing Updated
• CMS-10780 Appendix IV – Standard Notice Consent Updated
• CMS-10780 Crosswalk of changes
• CMS-10780 Supporting Statement 60d final
• CMS-10791 – HHS PRA Supporting Statement
• CMS-10791 – 1. Right to Receive a Good Faith Estimate of Expected Charges Notice
• CMS-10791 – 2. Good Faith Estimate Template
• CMS-10791 – 3. SDRE Declining Eligibility or Need More Information Notice
• CMS-10791 – 4. PPDR – Dispute Initiation Form
• CMS-10791 – 5. HHS – Appendix SDR Entity Certification Data Elements
• CMS-10791 – 6. HHS – Appendix Vendor Management (VM) Data Elements
• CMS-10791 – 7. HHS – Appendix PPDR Data Elements for Patients and Providers
• CMS-10791 – 8. PPDR – SDRE Determination Notice
• CMS-10791 – 9. PPDR – SDRE Selection Notice
• CMS-10791 – 10. PPDR – Payment Settlement Form
• CMS-10791 – 11. HHS – Appendix Good Faith Estimate Data Elements

For more information, please review the following resources:

Articles

• https://www.apaservices.org/practice/legal/managed/billing-disclosure-requirements?_ga=2.59623083.72268334.1639244942-2123816710.1622929053
• https://www.simplepractice.com/blog/no-surprises-act-good-faith-estimates/
• https://blog.aamft.org/#:~:text=The%20No%20Surprises%20Act%20established,omnibus%20pandemic%20spending%20relief%20bill
• https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-B/part-149/subpart-G/section-149.610

Government

• Centers for Medicare and Medicaid Services: https://www.cms.gov/nosurprises
• U.S. Department of Labor: https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/no-surprises-act
• https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-B/part-149/subpart-G/section-149.610

Other

• Center on Health Insurance Reforms at Georgetown University: https://www.cms.gov/nosurprises
• Kaiser Family Foundation: https://www.kff.org/health-reform/issue-brief/no-surprises-act-implementation-what-to-expect-in-2022/