Navigating The ‘No Surprises’ Act: An Essential Overview for Medical Practices

In 2022, the ‘No Surprises’ Act was implemented to establish legal requirements safeguarding patients and consumers from unexpected and distressing medical bills. Inaccurate payer network status and frequent referrals to out-of-network providers had taken a toll on patients, often leaving them in financial distress. Recognizing the need to prevent unforeseen financial burdens on patients, the ‘No Surprises’ Act introduces mandates and regulatory guidelines to curb excessive out-of-network billing. These regulations are equally pertinent to medical practices.


The legislation introduces the concept of Good Faith Estimates (GFE) to inform patients about the anticipated costs of a scheduled or requested healthcare item or service. These estimates should encompass all actions around this encounter, including any service from another provider or facility. Nevertheless, due to the intricate and extensive nature of the law's requirements, achieving transparency in this regard may sometimes seem like navigating through a complex and challenging process.

However, the repercussions of violations can be severe, making it essential for medical practices to be aware of the consequences they may face in the event of a violation. In this blog post, we delve into the specifics of the ‘No Surprises’ Act and its implications for medical practices.

The Five Mandates of The No Surprises Act For Medical Practices

The US department of Human and Health Services (HHS) has been on a mission to place patients at the center of their care process and the No Surprises Act is one such initiative. GFEs and a proactive approach to communicating them to the patients are the cornerstones of its mandates. They are the following:

Communicate benefits and standard charges: The No Surprises Act mandates medical practices to duly inform patients of their consumer rights and protections. This information must be displayed on the practice website and in the care facility where appointments are scheduled and patients approach the front desk with questions about care costs. 

Medical practices must make patients aware of their commitment to transparency by making pricing and billing information easily accessible. It instills confidence in patients and saves them from being burdened with surprise bills.

Ascertain the patient rights established by the ‘No Surprises’ Act: Practice owners must ascertain whether patients have active health insurance coverage. If they do, providers must also inquire about the patient's preference to submit a claim to their insurance plan for the services provided. The ‘No Surprises’ Act also safeguards uninsured or self-paying patients, particularly for non-emergency situations. Most importantly, in-network patients who receive services from out-of-network providers may qualify for specific protections.

Ideally, owners of medical practices should proactively ascertain the insurance status of patients to prevent misunderstandings and miscommunications. For even greater efficiency, identify and prioritize uninsured and out-of-network patients to minimize the risk of human error and unnecessary expenses.

Notify Patients of Their Right to a Good Faith Estimate (GFE): The ‘No Surprises’ Act requires healthcare facilities to provide a transparent assessment of expected costs, referred to as a Good Faith Estimate (GFE), to both uninsured individuals and insured patients who choose not to seek reimbursement from their health insurance. 

Every patient without insurance or choosing to self-pay must be informed about their eligibility for a GFE, regardless of whether they proceed with scheduling any services. Additionally, the ‘No Surprises’ Act seeks to expand this obligation to patients intending to seek reimbursement from their health insurance plan, necessitating the submission of a Good Faith Estimate to the plan or issuer. The Best Practice Institute has established standardized check-in procedures to ensure that eligible patients are made aware of their right to receive a GFE.

Balance Billing Restrictions: The legislation restricts balance billing for out-of-network emergency services or non-emergency services provided by out-of-network physicians within in-network facilities. In such instances, individuals are not permitted to receive direct bills from out-of-network providers or facilities, covering the gap between healthcare expenses and the insurance coverage.

Provide Accurate GFEs on Time and in Good Detail: According to the ‘No Surprises’ Act, if you schedule services for an uninsured or self-paying patient at least 3 business days in advance, you must give them a Good Faith Estimate (GFE) within one business day. If the services are scheduled at least 10 business days ahead, you have 3 business days to provide a GFE. Additionally, all uninsured and self-paying patients have the right to receive a GFE within 3 business days upon request, regardless of when the services are scheduled. It is recommended to keep patients informed by providing accurate estimates of their expected costs, including any out-of-network fees, before scheduled procedures. To streamline this process, consider automating the distribution of GFEs and utilize various methods such as email, text, and mail for delivery.


The Bottom Line for Medical Practices

With the implementation of the ‘No Surprises’ Act, real-time eligibility verification tools hold immense promise for medical practices. These tools allow medical practices to instantly confirm a patient's insurance coverage, network status, and benefit details. Such a proactive approach empowers healthcare providers to make informed decisions at the point of care, mitigating the risk of surprise bills and facilitating a smoother reimbursement process. In an era where regulatory compliance is paramount, integrating real-time eligibility verification tools becomes not just a convenience but an essential component in navigating the complexities of healthcare billing.

Interested to learn more about a powerful new real-time patient eligibility verification and claims check tool? Click on the link and follow this space for regular updates.