User Guide — No Surprise Billing FAQ

The No Surprises Act was signed into law on December 27, 2020 as part of the Consolidated Appropriations Act of 2021. The legislation became effective on January 1, 2022 (for claims with a Date of Service of January 1, 2022 or later).

The No Surprises Act:

• Protects patients from surprise medical bills for emergency services and certain services performed by out-of-network providers at in-network facilities
• Requires that providers and facilities provide patients good faith estimates of charges for scheduled health care services for uninsured (or self-pay patients), and provide insured patients good faith estimates if consenting to applicable out-of-network provider services at in-network facilities
• Establishes an independent dispute resolution (IDR) process to resolve payment disputes between a provider or health care facility and a patient's health plan

Your practice must determine whether your providers and care facilities are subject to the No Surprises Act requirements. Use of these athenaOne features does not guarantee compliance, but will facilitate your organization’s efforts to meet relevant regulations.This wording was reviewed and approved by athenahealth Compliance. (June 2023, INC1278874) Refer to the CMS resources below.

Resources from the Centers for Medicare and Medicaid Services:

• CMS: No Surprises Act
• CMS: Overview of rules & fact sheets
• CMS: What are the new protections

You can use the Self-Pay Cost Estimate tool to generate a cost estimate for self-pay patients when viewing an appointment that hasn't been checked in yet.

See To create a cost estimate for self-pay patient appointments for details.

Not currently. We’re investigating methods to reliably provide In Network/Out of Network status, which is necessary for determining whether the No Surprises Act applies, but no solution is available yet. As a reminder, scheduled (non-emergency) services only fall under No Surprises when the facility is in-network, the provider is out-of-network, and the facility falls under one of the following categories:

• Hospital
• Hospital Outpatient
• Hospital Critical Access Point
• Ambulatory Surgical Center

We’ll use the Place of Service code associated with the department configuration to determine if the claim is for Emergency or Non-emergency services.

The No Surprises Act covers the use of out-of-network Air Ambulances. Our current solutions aren’t intended to support those requirements, so if they apply to your organization, you’ll need to arrange internal procedures for remaining compliant.

Obtaining patient consent is your responsibility, and your organization should develop a policy for collecting evidence of consent.

The following athenaOne functionality was released in summer 2022 to help manage

out-of-network patient consent requirements.

• Flag upcoming appointments that allow for consent to balance bill (Out-of-Network Billing Consent).
• See the current Out-of-Network Billing Consent status for appointments.
• Manage Out-of-Network Billing Consent steps: Enter the expected procedure(s) and cost estimate, create consent form; send consent form to patient; attach a signed consent form to a patient's appointment.

• See the patient's consented amount and signed consent form and option to carry the consented amount from the appointment to Charge Entry and the claim.

• The athenaOne system uses the patient's consented amount, the payer payment amount, the adjudicated Patient Responsibility amount, and your Patient Billing Settings for Out-of-Network Providers, to determine the amount to bill the patient.

• The athenaOne system sends claims to HOLD or bills the patient, based on your configuration settings and the patient consented amount.

• Use claim worklists to resolve claims that are on HOLD for No Surprise Biling review.

For details, see the Step-by-Step Instructions in the User Guide — athenaOne Support for Compliance with No Surprise Billing Legislation.

Limitations:

• athenahealth is providing enhancements to help support compliance, but each practice will need to determine if the No Surprises Act obligations impact their organization, how to configure adjudication, and which new options they will use.
• Additional requirements, such as state laws on balance billing, may be applicable to your practice.
• We’ll continue to work closely with our customers to determine where additional enhancements in the athenaOne system can support compliance with any new requirements.

Consented amounts can be entered at various points:

• When you receive a signed patient consent form and attach it to their appointment, you can enter the Consented Amount in the Manage Out-of-Network Billing Consent pop-up window
• Any consented amount and signed consent form attached to an appointment will be available for reference in Charge Entry and the claim. You can view and edit the consented amount In the Service Type Add-On (STAO) named No Surprises Act Consent, which is available in both Charge Entry and Claim Edit.

For details, see the Step-by-Step Instructions in the User Guide — athenaOne Support for Compliance with No Surprise Billing Legislation.

Held claims are available in your Claim Inbox or Claim Worklist under the appropriate kick code.

For details, see the Step-by-Step Instructions for claims worklists for No Surprise Billing review in the User Guide — athenaOne Support for Compliance with No Surprise Billing Legislation.

If your Default Service Type Add-Ons include No Surprises Act Consent, then all your claims will have this STAO enabled.

If you don’t want it enabled for all claims, please open a case by navigating to the Contact Support page in the Success Community, or in athenaOne > Support > Create Case or Call, and we’ll be happy to help update the setting.

For details, see the Practice Settings section in the User Guide — athenaOne Support for Compliance with No Surprise Billing Legislation.

We continue to develop and improve solutions to support compliance with the No Surprises Act, and will provide release notes and updates in O-help as more information becomes available.