Legal Compliance Without Surprises: Assessing the Challenges

A WEDI forum addresses the challenges of providing consumers with accurate estimates of health expenditures before receiving services.


The No Surprises Act is based on the premise that cost-conscious consumers who obtain accurate information about health care prices before services are provided will be empowered to make more informed decisions.

The challenges facing suppliers in their early efforts to comply with the law by preparing simple, understandable and accurate quotes for consumers were discussed at the WEDI Summer Forum in Chicago on August 2-3.


Rob Tennant, Vice President of Federal Affairs, WEDI

Continued difficulties in contacting all suitable vendors and establishing an accurate cost estimate prompted WEDI to suggest further enforcement delays.


Many health actors taking steps to meet legal requirements struggle with several issues, including using standards to exchange price estimates, collecting all necessary information when multiple providers are involved, and consumer education on the law, noted speakers at the two-day event. .

Basics of the law

Among its provisions, the No Surprises Act requires health care providers to offer good faith cost estimates to self-paying or uninsured patients within three days of requesting or scheduling service, in part, to help avoid catastrophic “surprise” bills, such as for off-grid services.

Parts of the law went into effect on January 1, although the Department of Health and Human Services has postponed compliance enforcement actions until all necessary rules and regulations are in place and industry is deemed sufficiently ready to comply.


Beth Davis, Vice President, Payerpath Operations at Allscripts

“Several things in the new law not only seem unachievable…We believe it’s in the best interest of the patient, but how can we really get there?”


Provisions of the new law relating to emergency services – when patients seek care immediately and do not have time to find a provider in the network – prohibit “balanced billing”, said Michael Kolber, partner at Manatt , a professional services company. Balance billing occurs when a provider bills a patient for charges not covered by insurance.

The law also mandates the use of standard approaches to determine and regulate out-of-network rates for health services while providing consumers with a process to dispute charges. It sets out requirements for an advance explanation of benefits – which provides a good faith estimate of the cost of medical care – so that patients, especially self-paying or uninsured patients, can review the costs before care begins. are not provided.

Final rules on the Independent Dispute Resolution Process – a new way to resolve payment disputes with providers for certain out-of-network charges – and provisions for advanced EOBs and related provisions of the Consolidated Credits Act await review. White House approval and could be released in the coming weeks, Kolber said.

Rob Tennant, WEDI

In the meantime, health care organizations are moving forward in anticipation of what the final provisions of the law will look like, said Rob Tennant, vice president of federal affairs for WEDI. The organization, which advises the government on electronic data interchange issues, has formed a task force that focuses on areas of the law “that have not been clarified”, Tennant said.

Some of the hard-to-solve problems include:

  • A lack of machine-readable files containing pricing information for hospitals and insurers.
  • Discrepancies between the “rough” preliminary estimates made by providers’ and insurers’ patient cost calculators/estimators and the later, more precise and formal estimates given to patients to comply with the law without surprises. Calculators or website-based price menus generally provide rough or low estimates of what patients might be charged for services, while good faith estimates come after an in-person examination and after specific complications to the patient are taken into account in the pricing.
  • Current limited capabilities of healthcare organizations to produce accurate, good faith cost estimates and advanced EOBs as required by law.

Patients looking to compare costs between doctor’s offices for a particular procedure may receive quick estimates over the phone before being seen by a doctor, which can lead to inaccuracies, said Beth Davis, Payerpath vice president of operations. at Allscripts, a health software. seller. When a patient is subsequently examined and a more accurate estimate of costs is presented, those estimates may be materially different, and that could form the basis of an appeal of the patient’s charges, she noted.

WEDI has identified the complexities of determining which provider is responsible for compiling fees when multiple professional services are required for complex procedures, Tennant noted. Continued difficulties in contacting all suitable vendors and establishing an accurate cost estimate prompted WEDI to suggest further enforcement delays.

Some providers have indicated they are concerned that good faith estimates will reveal pricing information to competitors, said Terrence Cunningham, director of administrative simplification policy for the American Hospital Association.

And technical issues can make it difficult to provide accurate estimates, he added. “Technological sophistication varies greatly from vendor to vendor. Many vendors struggle to master this as it is a new process. »

Davis of Allscripts added: “Several things in the new law seem not only unworkable, but unworkable from the start. It may take time and adjustments until the industry learns to deal with it. We believe this is in the best interest of the patient, but how can we really get there?

Challenges for providers, payers

At the WEDI event, several organizations described their difficulties in complying with the Act.

HCSC – which runs Blue Cross/Blue Shield plans in five states – was able to “deliver a minimum viable product” by offering cost estimates after ensuring its practices were consistent across the plans it runs as well as with procedures from other Blues plans, said Chatterjee Saugata, its senior director of business solutions.

At the University of Chicago, some financial advisers struggled to gather the necessary information from electronic medical records they needed to make cost estimates, said Suzanne Lestina, executive director of access and revenue integrity for its health operations.

“My financial advisors aren’t trained to read medical records and they can’t read the doctor’s mind” when the notes in the record are vague, Lestina told the forum.

Even though the law has been in place since Jan. 1, consumer awareness is low, as evidenced by little litigation over the charges so far, Saugata and Lestina said. “Consumers really don’t have clarity on this. … We [often] need to spend a lot of time educating them,” Saugata said.

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