Navigating the No Surprises Act in the Clinical Laboratory Space

Jan 12, 2023 | Blogs

It has been a year since the federal No Surprises Act was passed on January 1, 2022 in an effort to prevent patients across the country from receiving unexpected medical bills in their mailbox. Bills for clinical laboratory services have notably remained a source of continued surprise billing despite the law’s provisions. Issues still exist around the parameters of when the law is in effect and circumstances when it contradicts itself.

Surprise and Balance Billing in the Medical Testing Laboratory Space

The No Surprises Act (NSA) is federal legislation that is designed to protect patients from surprise medical billing. “Surprise medical billing” occurs when a patient receives services from a facility or provider that is out-of-network and the patient is unaware that their services will not be covered by their insurance.

Balance billing occurs when an out-of-network provider bills the patient the difference between the provider’s charge amount and the payer’s allowed amount. This practice was often experienced when people received unplanned, or emergency care, which resulted in unexpected and high medical bills.

Balance billing has traditionally been a pain point in healthcare legislation as an ongoing issue that has been combated at the state level, but not overruled by the NSA.

The Lab’s Role in the No Surprises Act

The NSA applies primarily to surprise bills patients receive from nonparticipating providers of emergency services and from nonparticipating providers—like consulting specialists, radiology departments, and clinical laboratories—that provide services to a patient while receiving care for non-emergency services at a participating facility, such as a hospital.

Provisions of the NSA levelized patient cost-sharing obligations between participating and nonparticipating providers in the foregoing care settings and prohibit nonparticipating providers from balance billing patients for a cost-sharing amount higher than they would be charged by a participating provider or facility.

Medical testing and clinical laboratories fall uniquely into the circumstance where ongoing issues have arisen from in-network hospitals sending their patients’ lab work to out-of-network laboratories. The Morning Consult, a global research firm, found that since the release of the NSA, 32% of patients reported receiving unexpected bills. Both providers and laboratories alike that distribute bills that violate the act can face serious risks as legislation continues to shift around balance billing.

A Laboratory Billing Partner Can Help Your Lab Succeed Amidst No Surprises Act

Despite provisions to the act, labs face further hurdles in their ability to recover reimbursement in full compliance with the NSA in addition to other federal and state regulations. The payer landscape continually moves the ball in transparency of requirements of successful lab claims, patient coverage, and eligibility for labs to become in-network. Laboratories may find relief from these hurdles by working with trusted billing partners like Phytest that are dedicated to not only employing current compliance regulations, but researching and reporting all foreseen changes that will affect their clients.

Some ways that a third-party billing partner can help your laboratory improve billing processes while navigating the NSA include:

 

  • Customizing fee schedule rules based on individual payers. Incorporating specific rules into a claim-scrubbing engine will help prevent out-of-network claims from being charged more than upfront allowable in-network costs.
  • Providing experienced and efficient patient support. A team of on-shore patient support specialists will have the relevant knowledge to evaluate patient claims and questions surrounding claims that have been filed incorrectly under the NSA.
  • Identifying differences in network rates to present to lab stakeholders and their providers. This can be utilized to negotiate rates and establish agreed upon fee schedules that leverage out-of-network costs in agreement with the payer and provider.

 

The importance of laboratories partnering with competent billing vendors is greater than ever with legislation constantly shifting. Failure to comply with advancements in billing procedures, rates, and compliance can not only hurt labs financially, but ultimately prevents patients from receiving the financial transparency they deserve in seeking proper healthcare. Labs must look to informed and advanced billing partners that leverage expertise, technology, and customer service to deliver fully compliant services and educated support. Phytest has invested over 25 years into the laboratory industry as a service-focused partner to laboratories of all sizes and specialties.

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