Don't Be Surprised by the "No Surprises Act"

Hello folks, and happy Tuesday to you. My name is Lawrence Peplar, and I'm the Senior Client Success Manager over here at ChiroTouch Practice Management Software and Integrated Practice Solutions. And we are just overjoyed to bring you a really interesting and informative topic today.

We're gonna be talking about billing and coding and hints and tips. This issue of their series is going to focus on the No Surprises Act in effect this month. Are you in compliance?

Once again, we're fortunate enough to be partnering with Kathy Weidner, who is the de facto absolute, most astute professional when it comes to coding and compliance in our industry here. The superlatives that I could throw towards Kathy are never ending. Kathy, how are you doing this morning?

Well, I am Jim Dandy, and I'm always embarrassed by all of those superlatives love. Thank you for loving me. I appreciate that.

So, hey, folks, if you're not using the services over at KMC University, you ought to be, because there is no better service to help you with your billing and coding needs, and especially when it comes to getting in the weeds on coding and things of that nature, and new changes that are coming. Kathy helps us keep abreast of what's on the forefront, what's coming down the pipe, things that we need to be aware of before they even happen. So what are we gonna cover today?

Well, this overview is gonna cover these important aspects of this required law that affects providers. How the transparency piece applies to all providers, making them responsible for clearly communicating the cost of care to both insured and uninsured patients. And this includes chiropractors.

What's the definition of good faith estimate? And how some are expected to be no more than $400 off when estimating the cost of care. And then we're going to talk about some tips for building a process to provide this information in the most streamlined way with templates offered for your use.

So with that being said, Kathy's going to take just a little time, get your mind going, get you thinking about this topic and present some really good information to you. So I'm going to pass it over to you now, Kathy.

And I want to be clear, the government has certainly provided templates, which we are happy to share as files that can be posted where Lawrence and the team will post this recording. So we're happy to provide those. Obviously, we've kind of dug into it more and we have some additional things and we'll talk a little bit more about how those are available.

So I'm giving you a very targeted version of something that in our world is a five module course. It is so complicated. So don't expect that you're here to learn every detail of this.

That is certainly not what we either intend or what is even reasonably possible. So I want to just share kind of right up front. I'm going to go quickly.

So why did the government want to cramp our style like this? Well, the challenge is that this is about consumer protection and you don't have to go very far to find out about these challenges that have happened. Two big giant offenders have been ambulance services, particularly air ambulance services and these kind of pop-up emergency rooms that are all around.

I can throw a rock either east or west from my home and hit two of them because they're simply everywhere. Sometimes they're in urgent care, sometimes they're in emergency room. And the problem is they're facilities that perhaps out of network doctors work in, but you don't know that when you've cut your hand and you need something quick.

And then later you get a $10,000 bill and I'm not exaggerating. So this is where all this came from. We as providers got caught up in the mix.

I will tell you that even as of today, which is whatever the heck today is, January the 25th, there's still unanswered questions. So nobody has the right answers and anyone that tells you they do is blow and smoke. So I'm gonna tell you what we know, I'm gonna tell you what you should do, what you can do.

And as usual, our job is to be as practical as we can for you about what's going on. So we've had a really big kind of year starting in 2021 with the 21st Century Cures Act, with the new HIPAA changes to information blocking, HIPAA right of access changed, the HIPAA Privacy Rule and the proposed changes happened, and then boom, the No Surprises Act happened as well. So what we know their issues are, are hidden charges, the excessive balance billing that's happening, and the idea that the number one reason for bankruptcy in the United States is medical debt.

Now, I don't think our little world of chiropractors particularly are the problem here. But as I said, we've gotten kind of caught up in the process and there may be practices that you do in your office that are now going to be contrary to what they want you to do with this new law, which by the way, everything I'm telling you went into effect at the beginning of this month. So if you've done nothing on it, or are like nine out of 10 doctors who we speak to who call in and say, what?

It's what? What happened? It's not okay.

Like you have to stay on top of things. And I'm so grateful that ChiroTouch asked me to come and just share a little bit of information with you here. So surprise billing in and of itself is essentially, I wasn't expecting this to happen.

I had an interesting thing happen myself recently where I visited an ENT and I was still meeting my large deductible. And I noticed that I had a charge for $485 that passed through because it was applied to deductible for this endoscopic blah-dee-blah-blah, which wasn't endoscopic, but it was literally a camera that they put up on each side of my nostrils. I remember this distinctly.

And if this doctor spent four seconds, that's an exaggeration. She put this thing on her head, she went bloop, bloop in each side, and I got a $485 bill, which I freaked the frick out about. And you don't wanna, you know, us as billers and coders, right, we're the worst people to send a balance bill to.

And I fought it all the way to the ombudsman because it was not fair what she did. So a surprise bill is when you get something you're not expecting. And it often comes down to a non-participating provider or facility.

And remember, the facilities are what caused this problem in the first place. Now the difference is balance billing. Balance billing is when you're supposed to be writing something off that the patient ends up getting charged for.

In general terminology, that's what it means. So you are absolutely okay with charging the patient for their portions. But again, with no surprises, we do have to let them know what's what.

So remember, this is a consumer protection law, which means it affects your patients. So again, hidden charges, excessive balance billing, and the medical debt issue. Now, one of the first things that we're gonna talk about is understanding who you are in your practice and how you deal with things.

And I say this with all the love in my heart because we talked to so many doctors. There are some of you out there who don't know if you're in or out of network with a plan. And if you're out of network, you're billing anyway, and maybe mishandling what the patient should be paying.

So all of that has to be first. You've got to bring yourself up to speed with what you should know. It's Aetna, it's Aetna HMO, I'm in network, fine.

It's Blue Cross PPO plan, I'm not in network. And you have to know what these things are, because depending on those levels of participation, even if you call yourself an all cash based practice, you have to know these things. Because if I walk into your practice, and I have whatever insurance, and yes, you're a cash based practice, but I have Blue Cross Blue Shield that has out of network benefits, if I see you, you are affected by this act, and you need to be aware of that.

So there's two parts to this thing. The whole idea of when part one started, which was in July of last year, was to try to increase stakeholders transparency, to create competition, to have hospitals particularly have to list their fee schedules and things of that nature, because it would give us consumer pricing information, allow them to sort of shop a little bit, and what the ultimate goal was to increase competition. Now part two, where the final rule came out in September, is the one that we have to pay the closest attention to.

Number one, they established a resolution process. That was their big deal. If a person doesn't like what they got for a bill, there's a formal federal process they can go through.

You know what the problem is? They first hired the person in December to go create the process that was supposed to be in effect January 1st. So gospel according to Kathy, I'm gonna be aware of it, but I'm not worried about that right now.

Second thing, which we're gonna talk about a lot today is the good faith estimate. This 100% applies to us. The third thing is what's called an advanced EOB that has to come from the payer because this rule not only affected doctors, it affected payers.

Payers have to be in a position to be able to say, in a way, think about verification, here's what we expect the out of pocket cost on this to be. Now I will tell you, my own health plan, I belong to Kaiser Permanente here in Colorado, and they already do this because everything that they've been doing it for a few years, everything that I would have done if I chose to, I could request an estimate, and they would say, based on what we believe the coverage to be on the diagnosis and the process that's going to happen, we expect your portion to be X. Now, this is impossible right now.

It can't be done for everybody. So we don't even worry about this today. Patient provider dispute resolution, that's kind of this thing.

It's possible but unlikely. And then obviously there's an expansion of the rights to external review. This is the piece along with what we're going to call billing protections that we're going to focus on today because in my estimation to not blow your minds, I'm focusing on the things you need to know about those two pieces.

Number one, the rule requires providers to furnish a good faith estimate of expected charges upon request or scheduling. Now, we'll get into what that means. And providers are expected to inquire about insurance status at the time of scheduling the appointment.

Now, you may already do this. If you don't, you're going to have to get it added into your process because particularly those of you who maybe don't take, well, you're gonna have to do it either way because you could have people with no insurance or they have like a HMO that you're not a part of, et cetera. Healthcare providers and healthcare facilities are required under this to furnish a notification of good faith estimate of expected charges to anyone who is going to pay cash.

Now, who are these people? Anybody with insurance, but you're out of network with their insurance. Anybody who is exercising their HIPAA omnibus rights and they have insurance, but they're telling you not to bill it.

And anyone there to pay cash. These are all people that this applies to. And so what we're gonna show you definitely applies to those people.

Here's the big challenge. And to an individual who has not yet scheduled, but requests. So anybody can request this.

So what you need to do is have a process in place. Now, in fairness, I want you to know this has been such a moving target, even for our own clients, we have about 85% of the material that we would have available in the forms and all the things, we're 85% of the way there. Because we have two questions that we want the final answer to, out to both CMS and a set of health care attorneys before we finalize our material.

We expect that this week, our materials in complete, those of you that are members, you'll find it in the library here, by next week is our goal. By the way, also the launch of our brand new website, next week. So I want you to know, we don't even have all the final stuff.

Now, most of what the government provided is so heavily worded toward a facility that it sucks. It's not good stuff for us. There have been a few other consultants who put something together, and frankly, they did nothing more than take the government one and slap it on their letterhead.

We have created something for chiropractors and the way chiropractors practice. Because guess what? People call and you might get them in the same day as a new patient.

Now what do you do? You have these rules to follow. So that's kind of where we're moving in that direction, but I'm trying to be as transparent as I can.

We don't even have all the answers, but we will have by next week. And that will be the final answer here, or at least the answers we need today. So this is the issue that's been a big issue for people like us, because you have to be, according to this rule, able to supply your good faith estimate three business days before the date the service is rendered.

Now, is there a way around that? Yes, and I'm going to show you what that is. But you still have to make the patient aware.

It's a little bit like the wink-wink that could happen around an ABN. Well, if you want to get your papers at home and see all the stuff in the papers, in the papers, in the papers, you check option one and we'll go ahead and bill it. If you don't want any of that, you do number two.

Same story, we absolutely are required to be able to provide all of these estimates three days ahead. I'm more than happy to get you in today if you wish to waive that, or I can schedule you out far enough so that we could at least give you an estimate of these first day's charges. So most people are going to go, whatever.

They're, you know, what do you mean? What's the ballpark? The provider is responsible for the list of services.

Theoretically, this is the piece that I talked about is almost impossible now, but I want to let you know this is coming down the road. I don't know how far out. I hope it's way the heck far out, but you need to know this is that connection between the provider and the payer.

So our suggestion for you as a to do right now is make sure that you're enrolled in your payer portals so that when this comes to fruition, you're already at least set up to be where you need to be. The practices that are smaller practices, maybe you're not so involved with insurance, it's going to be less onerous. But if you're involved with insurances and you're not a part of that, you want to get busy on that.

Obviously, it's not possible by January. It's also was not possible even today. So the good faith estimate, as I said, is for those people self-paying, those who are insured using their omnibus HIPAA rights, and those who are insured but don't have benefits for your coverage or item.

We like to call that the election to self-pay. So I want laser, but laser is experimental according to my insurance company. Even if you're in network with a payer, and we think, oh, no surprises doesn't affect us here, it may be that if you're asking the patient to pay for their laser treatment, the good faith estimate has to come in place.

Now, are most of you good doctors and offices doing something anyway like this? I'm gonna bet that you are. If you're our member, of course, you already know how to do the election for the excluded services form that we have, because we've been asking doctors to do this for years.

It's just a good business practice to put something in writing and say, hey, this is not gonna be covered. If you want it, sign here. And it's quasi similar to an excluded services ABN or special notice for Medicare.

Now you may be wondering why I haven't said Medicare in any of this. This does not apply so much to Medicare patients, because billing protections are already built into the Medicare law. They're already there.

So somebody who, even if you're non-participating with Medicare, think about that. You don't have to tell them surprise billing, because you already know you can't charge more than the limiting fee. Now, when they become a cash-paying patient for maintenance care, at that point, maybe that's the time to do so.

But if you're continuing to charge the Medicare allowed fee or limiting fee, you don't even have to worry about that. So here's what's required for good faith estimate, or GFE as we're gonna call it. When the person calls for their appointment, if you don't do it now, you've got to work on a process to get this done.

For those of you who are members, this will all be part of the checklist that's in that course. But it's important to know, you need to ask them a series of questions. Are they insured?

Do they plan to use their insurance, et cetera? Now, it would be very simple, I assume, for most of you are going to be doing a new patient evaluation and management service on visit one. Now, let's not even talk about our new conditions and returning patients.

Let's just talk about new patients for now. It would not be hard for you, and this is certainly what we're advising our members to do, to go pull a 2021 coding audit, to be able to go, I want to see all of my E&M services for new patients, 9920 something, and I want to see what the ratio is of how many times I build each one. That's just a straight up coding audit.

And let's pretend for a minute that stupid numbers, 25% of the time it was an 02, 50% of the time it was an 03, 25% of the time it was an 04. And for demonstration sake only, my 99202 is $100, my 99203 is 150, and my 04 is 200. It would be very, very simple for me, because all you know right now, I don't care what you think you know, all you know right now, is that that person is going to get an E&M service.

Because that's really all you can guarantee. They come in, they have that evaluation. Do I take x-rays or not?

Do I treat or not? Those are decisions that happen after the patient's there, even if you work off of a protocol. So if I know that between $100 and $200 is what I can verbally estimate on the phone, because that's what I know, and the majority of those people are 150, that's a very easy thing you could say, simply by doing a little audit review of your information.

If the patient wants to get in the same day, you do need to tell them. I'm required to give you a written estimate of this, I can provide that when you get here later today, or I can send it to you if you're willing to schedule at least three days out. So that's a bunch of bollocks if you ask me, but it's just the rule of what you have to do.

So start with, what's your E&M service on visit one? Now, they can ask, and you have to send it. I'm going to show you kind of what the government has for a form for that.

But if it's not yet scheduled, they can ask for that estimate in writing. And it's a pain in the fanny, but they can do it and you have to comply. So we encourage you to really build a solid intake process.

Those that use our new patient telephone form, that's a great way to use that process because it lays out what the patient has or doesn't have in network, out of network. And then it allows you to verify and to know where you're at with them. Enroll with your payer porters for now, get that done.

Get medical review policies and reimbursement guidelines. You hear me say this all the time from the payers that you deal with so you know what is and isn't covered. Start a solid verification process that's in place before the patient comes in if you can and not just eligibility.

Verification of what actually is or isn't covered. And then really build your compliant financial policy. Figure out your coding averages, how many different of each one you did, and maybe you can figure out what you want to provide as verbal estimates on the phone.

Provide that written estimate at visit one, something that you could put together. My guess is it would be very easy to have a standard template, have what you normally do and then fill in that information. Then provide a more detailed one at your reported findings or financial reported findings, and most certainly keep it in between that ballpark of $400.

So if you're already doing some type of a good faith estimate, awesome. The little gory details are gonna still reveal themselves, I think over the next 30 to 60 days. Make sure that if it's an out of network person, that you deal with specifically that extra billing protections form that we talked about.

Now, in my mind, and certainly the way we're advising our members, is I still think it's a good idea to use the patient election to self pay form to double indemnify, so to speak, the fact that the patient says, no, no, I don't want to use my insurance, I want to do this. The other thing that you can do if you're worried about this initial visit situation, I know I've talked about it in these trainings before, and certainly we have this in our library as well, is what we call the pre-acceptance interview. That the way you manage new patients is that the patient comes in, they have a discussion with the doctor, that anybody can have a conversation because we don't want to call it a free consultation, but they can come meet the doctor, talk about their issue, determine whether they're a good fit, and because they're in, now you could give that more specific estimate of how much that first visit would be.

I love all of those ideas. I think at this point, it's about process, and even those that work with us one-on-one, every different coach is working differently with every single person because we don't want to upset your apple cart of your practice that much. We want to make it so you do what you need to do, but it's not overboard.

Kathy, thank you so much for joining us today. We appreciate you folks. Have a great day.

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