Physician Requirements

Provider obligations under the No Surprises Act include the following: 1) a prohibition on balance billing for out-of-network emergency services; 2) a prohibition on balance billing for non-emergency services by nonparticipating providers at certain participating health care facilities, unless notice and consent is obtained in some circumstances; 3) disclosure requirements to patients regarding protections against balance billing; 4) good faith estimate requirements for uninsured or self-pay individuals; 5) continuity of care requirements upon a network status change; and 6) directory and reimbursement requirements.

A more detailed discussion of each requirement is provided below.

Please note that these requirements do not apply to those individuals with coverage through other federal programs such as Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care, or TRICARE.  These federal programs have their own protections regarding balance billing. 

The NSA creates a process for providing notice to patients about the NSA balance billing protections and requirements for providers to obtain consent from patients to have patient protections under the NSA waived.

Providers must disclose the new protections against balance billing to certain patients.  Patients requiring disclosure include any participants, beneficiaries, or enrollees in a group health plan or group or individual health insurance coverage who receive items or services from your practice. 

When giving notice and seeking consent from individuals to waive their balance billing protections under the No Surprises Act, providers and facilities must use standard notice and consent documents developed by HHS. The standard notice and consent documents were published as part of CMS Form Number 10780 and are available for download on CMS.gov. Providers and facilities must tailor the standard notice with individual- and provider-specific information. 

The notice and consent exception does not apply to anesthesiology services. This is true for both emergency and non-emergency services.

Yes, the NSA and its rules provide requirements for improving provider directories and reimbursing enrollees that relied upon directories containing errors.

This provision pertains to providers or facilities that have or have had contractual relationships with a plan or issuer to provide items or services under plans or insurance coverage.

To improve provider directories, this provision requires that providers submit directory information to a plan or issuer—at a minimum—in the following circumstances:

• When a network agreement with a plan or issuer commences 

• When a network agreement with a plan or issuer is terminated 

• When material changes are made to the content of the provider directory information 

• When the plan or issuer requests such information, and 

• Whenever submission is deemed appropriate by a provider, facility, or HHS. 

This provision also requires providers to reimburse enrollees who paid a bill exceeding the in-network cost-sharing amount while relying on a provider directory containing an error. 

ASA is using its best efforts to provide accurate responses to your questions. However, these responses are intended as guidance and do not constitute legal advice, nor should they be construed as representing ASA policy (unless otherwise stated), making clinical recommendations, dictating payment policy, or substituting for the judgment of a physician and consultation with independent legal counsel. 

The No Surprises Act requires that all physicians and health care providers – both hospital and office-based – offer a good faith estimate (GFE) to uninsured or self-pay patients (including those with insurance that prefer not to file a claim) before scheduled services or upon request.

Physicians must generate cost estimates that capture all charges that likely will be incurred by the patient. Many physicians may generate estimates using the same billing systems that existed prior to the No Surprises Act, but some changes may be necessary to meet new regulatory requirements. The cost estimate should not be a generic estimate, but as specific as possible to be more accurate, thus a high-risk patient that may require more time or resources should be factored into the estimate. The GFE in general must be provided no later than three days prior to the procedure. 

Convening providers (those who scheduled the services), such as surgeons and pain medicine physicians must provide a GFE upfront. You may have already seen notices at your institutions informing patients of their right to a GFE. Anesthesiologists must provide a GFE for their anesthesia services to the convening provider (surgeon or proceduralist) as part of the overall, single GFE for a patient. However, a patient can now ask for a GFE from any physician, and thus whoever the patient asks by law becomes the convening provider. We don’t expect an anesthesiologist to be asked frequently, but if so, be prepared to provide one and/or work with your surgeon or proceduralist to comply. For details on this consult pages 4-6 of ASA’s Implementing the No Surprises Act Overview  PDF download. 

Some GFE implementation requirements have been paused by the federal agencies, but with each update the agencies provide more guidance on the GFE. For example, the start date for providing estimates as part of an Advanced Explanation of Benefits (AEOB) to insurers to provide to their beneficiaries was postponed by the federal agencies (the technology for this is in development). ASA will communicate updates as we obtain them. However, we encourage members to become familiar with the process and begin to formulate processes for complying with the current required GFE and for future requirements for AEOBs. Here are a few resources to get you started:

• Good Faith Estimate Template (cms.gov You are not required to use this PDF form, but it shows what must be captured in the form provided to the patient. Note that good faith estimates become part of the medical record.

• Implementing the No Surprises Act Overview This ASA PDF download has details about GFEs on pages 4-6.

The NSA rule does not include any type of requirement that out-of-network physicians be credentialed by the insurance company.

However, presumably, the physician must still be properly qualified and authorized to perform the services by the facility.