Advanced Explanation of Benefits
The “No Surprises Act,” which Congress enacted to keep patients from receiving unexpected medical bills resulting from out-of-network (OON) services, becomes law on January 1, 2022. The Act applies to billings for emergency and non-emergency services and establishes procedures for resolving payment disputes between providers and insurers via binding arbitration.
The Act also requires health plans and insurers to provide an Advanced Explanation of Benefits (EOB) for all scheduled services before delivering them. The EOB helps prevent surprise billings by including a cost estimate for each service in easily understandable language.
How Does An Advanced EOB Work?
To meet the Advanced EOB requirements under the No Surprises Act, the health plan must submit a document to the patient containing the following information:
- Whether the provider or facility is in-network or OON
- The contracted rate for the service if it is in-network
- A description of where to find info regarding in-network providers or facilities if the service is OON
- A good faith estimate from the provider or facility based on applicable medical billing codes
- An estimate of the amount payable under the plan
- An estimate of the patient’s cost-sharing responsibility
- An estimate of any accrued amounts the patient has already met regarding out-of-pocket maximums and deductibles
- Whether the proposed service is subject to medical management practices such as prior authorization, concurrent review or fail-first protocols
- A disclaimer informing the patient that all the listed costs are only estimates
- Any other information deemed appropriate by plan administrators
When Does An Advanced EOB Need To Be Submitted?
The timing for delivering an Advanced EOB depends on when the patient schedules the service or requests an estimate.
If the patient schedules the service three to nine days before the intended service date, the plan must submit it within one business day after receiving notification from the provider or facility. A scheduling time of 10 days or more from the date of the service will require the plan to provide the EOB within three business days of notification.
The patient can receive an Advanced EOB electronically or via postal mail. The provisions of the No Surprises Act do not require providers or facilities to ask which delivery method patients prefer.
Contact Us to Learn More About the Advanced EOB and No Surprises Act
The No Surprises Act and its Advanced EOB provisions will dramatically impact the patient billing process and a provider’s ability to receive payments. The legal team at Cohen Howard, LLP is available to answer all your EOB management questions. Contact us today.