In 2022, the Centers for Medicare and Medicaid Services (CMS) estimated that, once it got its help desk in place to receive patient No Surprises Act complaints, it would field about 22,000 disputes yearly. Instead, a recent report from the U.S. General Accounting Office (GAO) reveals that CMS received nearly 490,000 complaints from April 2022 through June 2023, a period of 14 months. That figure is 20 times their expectations. 

We all know that the No Surprises Act passed in 2022 and CMS began the process of receiving complaints in 2023. In the past two years, however, court cases brought by medical organizations (AMA, AHA, Texas Medical Association) stopped CMS from taking steps to evaluate alleged violations or assess penalties, which can amount to $10,000 per violation.  

Just this past January 2024, CMS  finalized its process that steps consumers through submitting complaints online in a way that complies with the legal restrictions placed upon it. In addition to email and website communication, the help desk also offers a phone number. When submitting via the website form, patients must upload documentation like good faith estimates, bills, and more. CMS reviews this material along with the consumer’s complaints and keeps them up to date on the progress of their matter. 

A handful of law firms have shared that their hospital clients have begun receiving requests for patient clinical and administrative documents. These document requests signal that CMS is undertaking NoSA enforcement. This said, given that it probably only prepared and staffed for 22,000 complaints and received 490,000, the resulting backlog will delay action for months. 

 Here, you can prepare yourself for your options should you start getting requests from attorneys.  

Curious about how good faith estimate software keeps healthcare organizations compliant with NoSA and increases upfront collections? Walk through a demo of how to automate that process here: 

What is No Surprises Act enforcement? 

The No Surprises Act is legislation passed in 2022 and enforced by several federal agencies. Each entity plays a specific role depending on the context of the healthcare services and the type of health insurance involved:

1. Health and Human Services (HHS), via the Centers for Medicare & Medicaid Services (CMS). The NoSA help desk is run through CMS, but HHS provides guidelines and updates involving the implementation of the Act.

2. Department of Labor (DOL): The DOL is responsible for enforcement related to employer-sponsored group health plans. They oversee compliance among employers and ensure that these plans adhere to the protections offered by the No Surprises Act.

3. Department of the Treasury: This department, often through the Internal Revenue Service (IRS), is involved in enforcement related to the tax implications and compliance of the No Surprises Act for health insurers and health plans.

The enforcement process typically involves oversight, investigation, and resolution of complaints related to surprise billing. Patients who believe they have been wrongly billed can file a complaint with the appropriate federal agency, which will then investigate the matter. If a violation is found, the agency can impose penalties, require corrective actions, and facilitate resolution between the billing party and the patient.

These agencies also work collaboratively to issue regulations, provide guidance to stakeholders, and publish FAQs to assist with compliance and understanding of the law. They monitor the practices of providers, insurers, and health plans to ensure compliance. Enforcement is generally assigned to the states unless the state cannot or will not carry out enforcement. Currently, only five states rely exclusively on the federal government for enforcement.

The No Surprises Act mandates that doctors and medical facilities must comply with these stipulations to avoid enforcement penalties:

• They must provide a good-faith estimate of services and costs to uninsured or self-paying patients who request such an estimate.
• They must accommodate an independent dispute resolution process to determine payments between out-of-network providers and health plans.
• They must accommodate a patient-provider dispute resolution process to determine payments between uninsured or self-paying patients and healthcare providers.
• They must provide a way to appeal certain health plan decisions for insured patients.

NoSA enforcement delays

With the passage of NoSA, the AHA and CMS received numerous requests from providers asking for a further extension on good-faith estimates, citing several serious unforeseen challenges in creating a comprehensive good-faith estimate.

The challenges cited were:

• The No Surprises Act requires providers and facilities to exchange billing information and codes with all co-providers and co-facilities. There is currently no system that allows unaffiliated providers to share information with affiliated providers. In other words, a doctor who treats patients in an in-network hospital cannot provide the hospital with an estimate for treatment; they can only bill after.
• Case management systems do not send bills and invoices to other providers but only to the insurance companies. Compliance with No Surprises Act regulations would require manual input for all estimates, which would likely take more time than the three-day limit set by No Surprises Act.
• There is no standardized system for sharing patient information, treatment codes, and other medical information in the manner required to create the estimate. AHA raised concerns that HIPAA restricts some of this data-sharing, hence the need to bill insurers directly.
• Without a standardized, automated system, provider variance and incompatibility between systems will likely lead to errors, additional delay, and increased administrative costs.

The American Health Association (AHA), AMA, and other groups worked to develop technical systems to resolve these issues. Now that they are resolved for the most part, the CMS help desk is open for business and taking disputes. 

NoSA enforcement today

At this time, the GAO shares that 61 percent of all NoSA complaints remain unresolved. Given that the figure was 490,000 in June 2023, we can assume that at this time the current number of cases is far higher. 

Further, according to the GAO, even when CMS rules in patients’ favor, recouping payments from healthcare organizations is difficult. One legal entity said that less than 10 percent of its disputes have been resolved, and only 3 percent of those had been both resolved and paid.

Impact of NoSA on providers, payers, and patients

The impetus for NoSA was the financial hardship of patients who had received large medical bills (surprises) after accessing out-of-network care. NoSA put emergency departments and others on alert that they were responsible for providing self-pay and uninsured patients with good faith estimates before providing treatment. This step often alerted the patient that they were seeking care out-of-network, prompting them to find providers in their network for far lower costs to themselves. NoSA’s aim to protect patients ended up providing them with a thorough education on health insurance during a time when copays and coinsurance skyrocketed. 

Recent research indicates that this goal has been achieved. One study from the Robert Wood Johnson Foundation interviewed federal and state regulators, as well as advocates for consumers, employers, payors, providers, and medical billing companies. The authors concluded that “the NoSA appears to be protecting patients from the most pervasive forms of balance billing.” However, given the newness of the law, insights are still limited. Assessing the impacts of NoSA on health insurance premiums, access to service, and payer or provider consolidation has yet to materialize.

Still, the national, independent, not-for-profit organization FAIR Health echoes this progress surrounding in-network usage. With access to 45 billion claim records, FAIR Health possesses the nation’s largest collection of private healthcare claims data. In its 2024 study of private healthcare claims filed from 2019 through 2023,  it found that during that period, in-network care increased 7.0 percent nationally, from 84.1 percent of claims in Q1 2019 to 90 percent in the third quarter of 2023. The increase ranged from 8.3 percent in the Midwest and South to 4.8 percent in the Northeast. While a trend for more in-network care was already beginning in 2019, this increase indicates that NoSA is helping patients avoid surprise bills that result from out-of-network care.  

How GFE software keeps you NoSA compliant

During a dire staffing shortage when new revenue cycle management FTEs are expensive, more healthcare organizations are turning to software to research, compile, and send their GFEs accurately. After all, the CMS itself lets providers know that compiling an accurate GFE manually requires 1.3 hours. Just 5 GFEs per day take up 6.5 hours, or nearly one FTE at a cost of $45,000 (including benefits.) Solving the GFE problem with manual labor drains revenues. 

Good faith estimate software lets you create compliant GFEs at a fraction of the cost of new FTEs. It also:

• streamlines eligibility and identifies patients who qualify for GFEs
• automatically sends GFE in digital and physical formats
• improves upfront and point-of-service patient payments
• improves patient trust and satisfaction
• saves valuable time for healthcare staff, making new hires unnecessary

If you think more GFE requests are coming your way, prepare by researching the pros and cons of additional manual labor vs. automated software solutions. 

Remain No Surprises Act compliant with MD Clarity

Clearly, the GFE is critical in remaining compliant with NoSA. Recently, using our Clarity Flow GFE tool,  we helped a women’s health group get 445 GFEs out every day so they would remain compliant. If they hadn’t chosen a software solution, they would have had to hire four to eight FTEs to handle this critical step in the patient journey manually. That choice threatened to cost them $172,00 to $344,00 annually, an amount they couldn’t afford.  

Clarity Flow accurately calculates patient financial responsibilities. It determines copays, coinsurance, and deductible amounts and lists them in an email, text, or letter that includes a link to easy upfront payment via your portal or another platform. Unlike most GFE software providers, Clarity Flow can be configured to send upon patient scheduling. Most clients find that 99 percent of estimates deploy successfully with no intervention from staff. Engineered for transparency, Clarity Flow substantially reduces patient worries about costs, leading to an enhanced healthcare experience.

Book a demo today to see first-hand how much of your manual work can be handled with automation, accuracy, and the ultimate in transparency.