No Surprise Billing Act: Guide to Compliance for Diagnostic Labs

What is the No Surprise Billing Act?

The No Surprise Billing Act (NSA) took effect on January 1st, 2022, and is a federal mandate that “protects people”, according to CMS “covered under group and individual health plans from receiving surprise medical bills when they receive most emergency services, non-emergency services from out-of-network providers at in-network facilities, and services from out-of-network air ambulance service providers.”

Before the NSA, having health insurance but receiving care from an out-of-network provider or facility could create surprise medical bills.

People who have Medicare and Medicaid already benefit from the protections offered by the No Surprise Billing Act — which aims to offer the same protections to those with private health insurance.

But what exactly does the NSA ban?

Here’s an overview…

• Ban surprise bills for emergency services.

• Ban out-of-network cost-sharing. Providers can’t charge more than in-network cost-sharing for these services.

• Ban out-of-network charges and balance bills for certain additional services.

• Require healthcare providers to give a notice explaining their protections under the NSA.

Now that you understand what the NSA is and have a general idea of how it works, let’s answer the more important question: how do you ensure that your diagnostic lab remains compliant?

How Laboratories Can Remain Compliant With the No Surprise Billing Act

Here are 8 steps to ensure that your diagnostic lab remains compliant with the new regulations set out by the No Surprise Billing Act.

1. Determine Whether NSA’s Billing Provisions Apply to Your Lab

The most difficult challenge for diagnostic labs in remaining compliant with the NSA regulations will be knowing whether or not the NSA’s balance billing provisions apply to their operation.

You might need to dive deeper into your systems than you have before.

To answer this question, you’ll need to quickly determine for each patient…

• If the laboratory testing was ordered as part of an emergency or non-emergency service.

• If the non-emergency laboratory testing was ordered at a participating or nonparticipating facility as part of a “visit”.

•  If the test was ordered at an urgent care center that is licensed to offer emergency services.

• What the patient’s in-network financial responsibility would be for any given test performed at an in-network facility. 

2. Review Your Data Gathering Processes

The NSA is forcing medical providers to create better processes for gathering data from their network and their patients.

Labs aren’t excluded.

Take a look at your current data-gathering processes and ask yourself if they’re adequate to remain compliant with the NSA.

Important data to collect for each patient includes…

• Care setting where the test is ordered.

• Demographic and insurance data.

• Insurance verification.

• Health plan requirements.

• Medical necessity screening.

In addition, diagnostic labs should obtain all required authorizations, communicate accurate cost estimates for patients, and be capable of quickly providing accurate cost estimates. 

3. Provide Advanced Explanation of Benefits (EOB)

Under the NSA, health providers are required to provide a timely Explanation of Benefits (EOB) in plain language to their customers.

This EOB must include…

• Whether the provider or facility is participating and, if participating, the contracted rate. If the provider or facility is out-of-network, the description must reference how the patient can find information on participating physicians at the facility.

• The good-faith estimate from the provider based on codes

• A good-faith estimate of the amount the plan is responsible for paying based on the estimate

• A good-faith estimate of cost-sharing based on the provider’s estimate

• A good-faith estimate of the amount met by the patient towards out-of-pocket maximum and deductible

• A disclaimer that coverage is subject to medical management requirements, if applicable

• A disclaimer that the information is only an estimate and may be subject to change

• Any other information or disclaimer the plan deems appropriate

But how does this requirement apply to diagnostic labs?

The most important thing is that you’re sharing data efficiently with hospitals and providers and you should be able to provide patients a one-page notice that introduces the protections of the NSA.

4. Establish a Process to Keep Provider Directories up to Date

The NSA was just introduced.

And the federal government isn’t expecting everything to work smoothly right out of the gate.

However, by 2022, providers and payers must have a thought-out and clear-cut process for systematically following all of the regulations.

As a diagnostic lab, it’s your responsibility to keep your provider directors up to date and as interoperable as possible.

Erroneous provider directories will result in inaccurate estimates of in-network rates, which will cause problems with NSA regulations.

5. Review Contracts and Expand Out-of-Network Mitigation Strategies

With the introduction of the NSA, now is a good time to review out-of-network provider status as well as in-network contracts.

Review the contract that you have in place, then reach out and negotiate to create more helpful and efficient agreements based on the new NSA regulations.

Clear communication with patients is key to remaining compliant with the NSA — but that can only occur if your lab is also clearly and efficiently communicating with primary insurance providers.

6. Make Your Voice Heard

The comment period for this IFR is now open. And the next period will open in September. Make sure to reach out with feedback.

Final Thoughts on The No Surprise Billing Act for Diagnostic Labs

For businesses in the health industry, the No Surprise Billing Act has caused a lot of changes.

And in this article, we’ve taken some time to review what those changes mean for diagnostic labs. Specifically, we’ve outlined 6 steps that we think diagnostic labs should take to remain compliant.