The No Surprises Act Compliance 411 By Payspan

The No Surprises Act was proposed to create an impact on two main areas of the medical economy: transparency in information, and fair billing. This can potentially bring about a radical transformation in the competitive healthcare landscape of the United States today.

One of the most prominent features of the No Surprises Act is the delivery of fair estimates for all healthcare treatments and items, along with a comprehensive advanced Explanation Of Benefits. With Payspan, you can now make the most of your rights as a provider, payer, or consumer, and reap the many opportunities and benefits that come with the implementation of this revolutionary Act.

To protect patients from surprise bills and payment disputes, the rule establishes that, for emergency services and certain non-emergency services furnished by Out-of-Network providers at certain in-network facilities, the patient pays a cost-sharing rate similar to that imposed in-network.

According to CMS, the rate for this cost sharing is calculated based on a state All-Payer Model Agreement, specified state law, or, if neither of these apply, the qualifying payment amount (QPA). The QPA is generally the plan or issuer’s median contracted rate for the same or similar service in the specific geographic area.

Patient Engagement

Understanding legislation and regulatory changes

To help you better understand the workflow, here is a summary of what you can expect:

  • A patient schedules an appointment with a healthcare provider
  • Insured Patients: The provider verifies information and validates the insurance with the patient’s current health plan and sends Good Faith Estimate to health plan.
  • Uninsured Patients: The provider proceeds to creates and sends a Good Faith Estimate for the expected treatment and supplemental care to the uninsured patient.
  • The health plan creates a comprehensive Advanced Explanation of Benefits and sends it to the member, as well as the healthcare provider.


Timeline for legislation enforcement

A mandated compliance date was set for industry implementation of the No Surprises Act via an Interim Final Rule. Although, the rule does not directly address Advanced EOBs, stakeholders were expected to implement the requirements using a good faith, reasonable interpretation of the statue by January 1, 2022. However, in August 2021, CMS published FAQ guidance indicating that the Department of Health and Human Services (HHS) will delay the issuance of regulations and defer enforcement activity for Advanced EOBs, Good Faith Estimates for those enrolled in a health plan, and other requirements of the No Surprises Act. The effective date for compliance and enforcement is July 1, 2022

Provider-Healthplan persona together

Partnering with Payspan to meet your needs:

Here’s where we step in, as always, to simplify the process and help you ease into the transition. The two main components of the regulatory changes that fit within Payspan’s model of service are:

  • Advanced Explanation of Benefits (EOB): Updating the Advanced EOB sent to members to include comprehensive information regarding the cost of their care prior to the actual service/appointment date.
  • Qualifying Payment Amount (QPA): Updating the payment amount sent to the provider that indicates what portion of the service qualifies for reimbursement by the payer.

Payspan enables you to:

  • Provide consumers with the personalized experience they seek
  • Customize forms and channels based on consumer preference
  • Leverage our User Interface to integrate with your own member portal
  • Utilize our API to build your own customized experience with PDF statement rendering and printing capabilities.
  • Create and modify your EOB design
  • Determine which communication is required for your needs, i.e. Advanced EOB for members, or Qualifying Payment Amount (QPA) for providers.

Changes, in life or law, can feel overwhelming at first – but our team at Payspan is here to provide you with all the information, guidance, and solutions you need to remain abreast with the most current government orders.

Talk With a Healthcare Payment Specialist