There are many topics that have attracted a full seat for the webinar, but recently “Open the No Accident Act” The presentation made by Experian Health is excellent. Participants listened attentively to the general parameters and compliance standards that make up the regulation and the goals the regulation aims to achieve. During the 1-hour webinar, more than 130 questions poured in, and these questions continued to emerge as the event ended. Read our blog to learn more about “No Accidental Law”.
Big catch: There are many problems within the scope of healthcare participants. We reviewed the content submitted during the webinar, grouped similar content together, and categorized them. Then, we asked the experts we worked with to better understand “No Accident Law”-Stanley Nachimson, the head of Nachimson Advisors*, to learn more about some of the most common issues. **
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General range
Who does this regulation apply to? insurance? No insurance?
The “No Accident Law” aims to protect uninsured, self-paid patients and patients covered by commercial insurance. It does not apply to government-reimbursed care, namely Medicare and Medicaid—mainly because these payers have banned balance billing. On the other hand, the regulations generally apply to all healthcare providers.
Is this limited to “urgent care” and is urgent care defined?
This regulation is made to ensure that patients are only responsible for in-network expenses related to emergency services or scheduled services of any hospital.
As for the definition of “emergency”, the regulations define emergency medical conditions as Expressed in acute symptoms (including severe pain) severe enough that a cautious layman with general health and medical knowledge can reasonably expect that failure to seek medical attention will result in: a) putting the patient’s health in serious danger; b) Serious impairment of bodily functions; c) Serious dysfunction of any organ or part of the body.
Does the “No Accident Act” replace state laws?
In states where there is no similar law to prevent balance billing, federal regulations are the default. In states that do have laws to solve this problem, when state laws provide less protection for patients, the NSA will give priority to them. In addition, in states that have enacted accident-free regulations, federal laws follow state laws and stipulate that full insurance plans must pay providers for accidental OON services, rather than requiring arbitration under federal regulations.
Is there an explanation on how to implement it?
As some entities have been affected, enforcement procedures are still under development. Three levels of law enforcement are proposed:
- State law enforcement-the state will assume the primary responsibility for law enforcement, and CMS will intervene in states that do not enforce the law or “fail”[s] Effectively implement the “law”
- Civil penalty (US$10,000 per violation)
- Possible mechanisms that can initiate enforcement actions that have been discussed include patient reporting tools and market behavior surveys initiated by CMS.
Operational impact
What are the main provider workflows affected by the No Accident Act?
The biggest impact will be around scheduling, estimating, and generating good faith estimates (GFE). The systems and solutions used to determine qualifications and coverage will put additional pressure on accuracy. At this time, if necessary or necessary, the mechanism to ensure that patients agree to OON services will also play a role. The law requires that the front-end operation be placed under the microscope as to the expected time when the GFE will be provided. The challenge of which entity is responsible for forming the “convening provider” of the GFE is a major issue. The convening provider must submit the GFE to the health plan of the insured patient in a standard format; or communicate to the patient the need for substantial changes to the workflow in a clear and understandable manner. The latest CMS guidelines state that for uninsured patients, the implementation of the rules will be delayed by one year, requiring providers to obtain estimates from other providers involved in care.
Does the regulation include office visits? Radiology? Laboratory work?
It seems so. The industry is questioning the scope of services required. Any pre-declaration of benefits that includes providers outside the network must include information on how to find providers within the network for these services. This is definitely one of the legal areas that the healthcare community hopes to help shape.
Is there a best practice for identifying OON status?
Most providers should be aware of the network status of any of their health plans. This will be a question to be answered at the level of the medical system and most likely individual provider facilities. However, determining the network status of other providers can be a problem. Most health plans have a provider directory for their members or use on their website. In addition to the very clear expectations of the law, there may not be a “standard”, that is, unless the patient agrees, no one will pay a balance for any OON care received. The system required to meet this compliance standard and the communication and protocol with the payer will be unique for different facilities. This sounds too simple, but the best course of action is probably not to balance the cost of care that patients receive without their consent.
Specification
Will the CMS provide standardized documents, and if so, do they need them?
Regardless of the file format, there is a set of requirements for patient notification. These include:
- The provider or facility is OON’s statement (if this is the case)
- Itemized, well-intentioned estimates of care costs
- Information about prior authorization and use management restrictions
- The notification must be in a format that the patient understands and is easily accessible (ie, in the preferred language and different from other documents).
Various model forms and notifications are provided on CMS “Overview of Rules and Fact Sheets” Page:
- Standard notification and consent forms for non-participating providers and emergency facilities, involving consumers’ consent for balanced billing protection:
Download the surprise bill protection form - Model disclosure notices for providers, facilities, health plans, and insurance companies to protect patients from accidental billing:
Download patient rights and protection against accidental medical bills - The Paperwork Reduction Act (PRA) of the Federal Independent Dispute Resolution Process Model Notice and Information Collection Requirements:
Download model notification and information requirements - Paperwork Reduction Act (PRA) model notification and information collection requirements for good faith estimation and patient-provider payment dispute resolution
Download model notification and information requirements
In addition, the Ministry of Labor has issued a Model notice Its a link on the accident-free bill overview page.
Which entity is considered the “lead party” and is responsible for coordinating the GFE, consent form, and other documents required to demonstrate compliance?
It is widely expected that the “lead” or “convening provider” entity will become a dispatch provider, but it has not yet been formally established. This is another area that requires input from multiple stakeholders.
Which parts of the law have been postponed?
The good faith estimate of the insured has been postponed, “until the rule-making of this requirement is fully implemented…is adopted and applied.” Establish the necessary systems to achieve this goal before January 1, 2015. Incorrect estimate.
Likewise, the advanced interpretation of benefits (AEOB) is expected to be postponed until the data transmission system and other requirements to provide patients with accurate AEOBs are in place. It is expected that HHS will take short-term remedial measures for this.
It is important to note that these delays in execution will not change the core of the rule, which prohibits balanced billing for OON care and services that patients do not know and disagree with.
*Stanley Nachimson is not an employee or representative of Experian Health.
** The scope and details of the No Accident Law are evolving. The information provided here is current as of November 18, 2021.
This content is for information and educational purposes only. Experian Health cannot and will not provide legal and compliance guidanceIt is recommended that all organizations thoroughly review regulations and seek appropriate legal and compliance guidance to determine appropriate compliance strategies. Experian Health provides solutions throughout the healthcare process—including patient participation, revenue cycle management, identity management, care management, and analysis—that may help meet compliance requirements.
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