Jay Holmes: Welcome to the Medical Management Podcast. A podcast focused on helping you level up your practice. Through interviews with some of the most successful leaders in the industry, we help uncover resources, tools, and ideas to help you level up your practice. Thanks for tuning in, and we hope you enjoy today's program.
Jesse Arnoldson: Hello and welcome to the MedMan podcast, I'm your host Jesse Arnoldson! Today we are going to be jumping into a topic that's been really, kind of, surprisingly controversial as of recently, the No Surprises Billing Act brought on by the Biden administration. I'm bringing one of my favorite people alive onto the show, he's one of our MedMan administrators that works for Women's Health Associates in Boise, Idaho. His name is Scott Tucker. Welcome to the show, Scott, welcome back!
Scott Tucker: Welcome, thank you!
Jesse Arnoldson: I'm excited because we, you know this is, for its namesake being the No Surprises Billing Act, I think we got into like the beginning of January and everybody was like, oh! Oh crap! Like this thing kind of snuck up on, you know, we're all trying to figure out how it works, and a lot of it is hospital-based, so how much applies to us? So, you know, for our listeners, Scott, and I really want to try and break it down and make it so that it's easier on you to be able to implement it and do it right and not overcomplicate it to the point where it just adds a ton more work to your already full plate. So Scott, do you want to maybe give us just a laymen version of what the no, No Surprises Act is or is supposed to do?
Scott Tucker: Yeah. So it really comes from people's frustration with not understanding medical bills and how they work.
Jesse Arnoldson: Right.
Scott Tucker: You know, to their credit, and it's validated it. All of us have gotten them and you get confused on what is what, who's billing for what, a lot of it surrounds mainly in a hospital stays, because you've got hospital services and, you know, have the independent providers, radiology, anesthesia, lab, surgeons and whatnot that provide those services and bill for those services. And the other complicating factor that goes into this is in-network versus out-of-network, what's a covered service, what's a non-covered service, the complexity of the insurance world, and their rules regulations. Understanding that one insurance, you know, take one of the bigger payers that Blue Cross Blue Shield, Aetna United Healthcare, you know, they're all big payers, but they have dozens and hundreds of different plans within even their own payer, and those plans have their own specific rules, so it gets complicated. So I think this effort is to help patients navigate estimated costs.
Jesse Arnoldson: Especially those that are self-pay or maybe underinsured, ... and even more so those that land out a network, right? That's really who is hit.
Scott Tucker: Agreed and the other, the other group that I know are starting to see more quote-unquote in the self-pay world are the patients that have these because they can't afford these high-deductible plans.
Jesse Arnoldson: High-deductible plans, yeah.
Scott Tucker: They know they're in general outside of something major happening, they're not going to hit their deductible. So when they have regular services for sinus infection or whatever, they sometimes opt to not even bill insurance and pay self-pay, because depending on where you go, you can get a higher discounted rate for paying right that in full than you do billing your commercial insurance and they're contractual out of this.
Jesse Arnoldson: Right. Just one more kind of unintended consequence of these high-deductible plans that are meant to be there so that people can afford to get insurance. But boy, that leaves a wake of problems for those at ... and those that have to deal with them. So OK, so we know, we know what it's supposed to do, it's supposed to help these people that we've described get a better idea of what their costs might be, at least get an estimate of what costs might be for the health care they're about to receive, that's the intended end result, right?
Scott Tucker: Yes.
Jesse Arnoldson: Now, a lot of the law has to do with hospitals, we know that, but there is some that has to do with outpatient medical clinics.
Scott Tucker: Absolutely.
Jesse Arnoldson: Can you maybe tell us the key components that apply to us?
Scott Tucker: Yeah. So the biggest piece that, that applies, so obviously, the No Surprises Act has the emergency situation as a completely different set of guidelines and expectations of both the outpatient and inpatient side of things. But for the outpatient side of things, the expectation for us as outpatient practices is that if we have a patient that is out of network or self-pay for whatever reason, either by their choice or by just being under or not covered, or they want to get a service that is a non-COVID service under their plan, the expectation is that prior to that appointment, they get a good faith estimate, is what it's called, showing the estimated costs of services that they may receive. Where that gets complicated for us is trying to determine what those are in order to provide this estimate for patients. The fortunate part of the No Surprises Act is they do give us some wiggle room, it's four hundred dollars, so if the estimate that we provide is four hundred dollars less than or less than four hundred dollars difference into what they're actually charged, they really can't dispute it. I mean, they can try, but that's the wiggle room, the grace period that's in there, but anything ... dollars, they can pay the twenty-five dollar fee to the government and do a dispute of the bill.
Jesse Arnoldson: So for us, you know, I think that a lot of, you and I have talked about this, it's intended to take away a lot of the surprises. My opinion is that it's one step closer to everybody's charges being very transparent, right, fee schedule being on the website, that's where I think this is going. With that in mind, what does a practice, what are the basic bullet points, okay, you need to have X, Y, Z, this form, done this time, what are those steps that a practice needs to take to ensure they're being as compliant as possible with the law?
Scott Tucker: So the good faith estimate, there's a couple components that it has to be, one is the reason for the visit and the good faith estimate does specifically state diagnosis codes, the more I read about it, and I think looking into it, it's impossible to truly come up with a diagnosis code before we ....
Jesse Arnoldson: Yeah, you can't do that.
Scott Tucker: But I think giving some more context to coming in for a sinus infection or something along those lines, and then the next piece is laying out the potential services for what they might receive and what that fee is. Obviously, before we see the patient, we have no idea what the level of visits going to be. So I think it's reasonable and practical to somehow line that out, whether you list each level and what that fee would be, or you just say this is our range, there's definitely a few ways to do it, but the goal being the patient shouldn't be surprised at what they're going to be billed for the visit. Then you get into lab testing and point of care testing and whatnot and I think that's where it gets a little more tricky, but we all have the common things we do for said problem, and you can still provide some estimate with there, you just have a disclaimer that you may get other stuff done, feel free to ask for the estimate before it's done, and we can provide that for you. The last piece that has to be in there is the disclaimers. And if you just go to the No Surprises Act, it's about one page of disclaimers that you have to have in your good faith estimate, it's cam language from the government, it's not even created, but it basically describes what the good faith estimate is, what the No Surprises Act is for, and then it gives you the resources if you want to dispute your bill, how the, how you go about that, and everybody needs to keep in mind that is not on us to deal with that. They have to initiate that with CMS and HHS. And obviously in the, the fact finding of that, we can get involved, but they don't file that dispute with us and and they need to file that with the government.
Jesse Arnoldson: Yeah, it goes directly through the government. Yeah. Well, good. I think that's super helpful, you know, we, in thinking about the practical side of it, for us in a pediatrics clinic, we did kind of what you described, we have our range of new patient CPT codes, we have a range of established patient CPT codes, we have CPT codes for vaccines, some of the most common labs that we do. And then, yeah, we have the disclaimers saying, hey, if there's anything else, ask, do you feel free to ask before we do it, if it's not in one of these buckets. Labs is definitely where it gets tricky because we feel pretty good, like we're not going to be off by more than $400 dollars if we account for at least an ENM and a vaccine administration like we're going to be within 400, but we start getting into labs all of a sudden that could be tricky. But again, you know, we, it depends on whether you do pass your billing or no. Women's health as you guys do a lot of pass your billing, so women's health associates would be kind of stuck with it, ... We don't, you know, we pass a lot of that off to our, our third-party biller or a third-party lab partner, and they have to do the billing. Any idea of how that is accounted for if they do labs and they're billed directly by the lab company?
Scott Tucker: So this is, you know, this is where it gets a little tricky when you're reading. So.
Jesse Arnoldson: Yeah.
Scott Tucker: You as the auditing provider have nothing to do with the lab and their fees. The way you read the rule is, is really the lab company should be providing this good faith estimate to those patients. Now practically.
Jesse Arnoldson: Right.
Scott Tucker: You see a patient in the clinic, the provider orders the labs, you draw the labs right there and send it to the lab, they don't really even have an opportunity to know that this is a self-pay patient.
Jesse Arnoldson: Yeah!
Scott Tucker: So I think that is a challenge. And then we also have to remember, specifically in Idaho, we've got the Ideal Patient Act, where.
Jesse Arnoldson: Right.
Scott Tucker: At now goes into some of this, as well as the disclaimers and the notifications you have to alert your patients of potential third-party bills they may receive so that that one gets gets kind of tricky, and there's definitely pros and cons to pass through billing. When it comes to this it makes it actually a little easier because we have these costs, but if not, it's tricky.
Jesse Arnoldson: Yeah, definitely. Okay. Well, I think that's all super helpful. Scott, remind us one more time if we're wanting to get that cam language, I'm assuming we would just Google, No Surprises Act disclaimer language or something like that.
Scott Tucker: If you google the No Surprises Billing Act consent form template, the very first thing that pops up is from the CMS, so it's straight from CMS.gov. And it has all the.
Jesse Arnoldson: Perfect.
Scott Tucker: It's supposed to be in there as far as also the requirements that are supposed to be in a good faith estimate.
Jesse Arnoldson: Okay. Well, thank you, Scott. I sure appreciate you being willing to pinch hit on such a not so fun topic, regulatory compliance and overbilling like that. Thank you for jumping in.
Jesse Arnoldson: Absolutely.
Scott Tucker: And Scott's going to join us this next week as well for a much more fun topic as we get into how to handle employee requests for pay raises. We'll have you back here in just a little while, Scott.
Scott Tucker: All right. Sounds great.
Jesse Arnoldson: Thank you, everybody for tuning in today. I hope that this was helpful. For all of the show notes, resources, anything else that MedMan does, please visit us at MedMan.com, and please tune in next week, we'll see you then.
Jay Holmes: Thanks for tuning in to the Medical Management Podcast. We hope you enjoyed today's featured guest. For the show notes, transcripts, resources, and everything else, MedMan does to help you level up, be sure to visit us at MedMan.com.
The Medical Management Podcast is truly happy to be back with much more information to help you level up your practice. In this two-part special we feature our friend Scott Tucker. In this first episode, we tackle a controversial topic: the No Surprises Billing Act of 2022. Even though this act applies in its majority to hospital settings, there is a part that applies for outpatient medical clinics and practices. Good faith estimates and disclaimers must be shown to patients. Hospitals and practices are not involved when a patient disputes a bill, that must be done directly with the government.
Scott breaks down the No Surprises Billing Act step by step for you to understand and know how to go forward from now on.
About our guest – Scott Tucker
Scott Tucker is a practice administrator in MedMan, working in Women’s Health Associates in Boise, Idaho. With a diverse background, he began working in public safety at the age of 14 when he joined the local fire department. He got his EMT at the age of 18 and has experience in the revenue cycle and practice management.
Scott developed a big passion for emergency medicine and nowadays still works as a paramedic.
The No Surprises Billing Act was designed to help people understand their medical bills.
Healthcare payers have different types of plans with a specific set of rules.
Sometimes patients prefer to self-pay instead of billing their insurance because it may be less expensive.
With a “good faith estimate” patients can know an approximate fee for the treatment, visits, and procedures they need beforehand.