No Surprises in Your Chiropractic Practice

At the beginning of 2022, a new law, known as the No Surprises Act, went into effect. While most of us are probably up to speed on the new requirements, some chiropractors are still out there who aren’t compliant. If you’re one of them or if you’re unsure about the basics of the new rules, this blog post is for you.

The No Surprises Act is a part of the greater Consolidated Appropriations Act of 2021, which was passed into law in December 2020.[1] The purpose of the legislation is to protect healthcare consumers by addressing the pervasive issue of medical debt and improving transparency in medical billing practices. Much of the law targets healthcare facilities that provide emergency services or utilize a combination of network and non-network providers like hospitals, out-patient facilities, and transport services. But the scope of the law does not end there. Several elements apply to all providers and private practices who treat and bill any self-pay patients or provide non-covered or out-of-network services to insured patients, and chiropractic practices are no exception.

Two essential requirements must be met right away:

Notice of Patients’ Rights   
A one-page disclosure describing patients’ rights under the new law should be posted prominently in your physical office wherever discussions about finances take place. It should also be published and easily accessible on your website. CMS has a sample notice available for reference or download online. It can be accessed here: (No Surprises: Understand your rights against surprise medical bills (cms.gov))

Good Faith Estimates
Self-pay patients are entitled to receive a “good faith estimate” of the cost of care. This estimate is fairly simple. It’s a disclosure of the services and the associated charges you expect your patient to receive. It should be as accurate as possible, but since it’s an estimate and not a payment contract, deviations are allowed if and when the patient’s case demands it.  

Many chiropractic offices (especially all-cash practices) already include thorough financial disclosures in their standard new patient procedures, but the new requirements include more than just the estimate itself. They cover timing and documentation, too. By law, good faith estimates must be provided “in advance of scheduled services, or upon request.”[2] This means that an estimate should be presented at the time of scheduling and pre-appointment registration (i.e., over the phone or online). It should then be reviewed again when the patient shows up for their appointment and before any billable services start. Also, since the requirement applies to new and established patients, an estimate must be provided whenever a change to the treatment plan alters a patient’s financial responsibility or whenever a patient asks for one.

Documents, Documents, Documents

As usual, how you document these interactions matters. Your good faith estimate paperwork should include an acknowledgment that the patient signs. It should state that the estimate was provided and reviewed. It should also note that the patient had the opportunity to ask questions about it (as long as you legitimately give them the chance to ask). The signed copy then becomes part of the patient’s file, and a second copy goes to the patient for their records.

When creating your estimate forms, be sure to include procedure codes and consider any outside services that will be performed “in conjunction with the primary item or service, including items or services that may be provided by other providers or services.”[3] For example, if your standard work-up requires outside labs, x-rays, or other diagnostic testing, those charges should be included.

Disputes and Penalties

The No Surprises Act provides patients with a clear process for disputes. Bills exceeding the associated estimate by $400 or more can be formally disputed when filed within 120 days of the bill date. (More information about the dispute process and a link for dispute submissions is available online at https://www.cms.gov/nosurprises/consumers.)

As we’ve seen with other laws like HIPAA, penalties for non-compliance can be hefty and random inspections of providers or facilities are possible. Monetary penalties of up to $10,000[4] per violation can be levied in addition to mandated patient refunds.

If you aren’t already offering estimates to your self-pay patients, don’t wait. Sample forms are available online that can be downloaded and put to use right away: Notice & Consent Form Example (cms.gov), CMS-10791 | CMS. They might not fit your preferred style, but they will get the job done until you can create or find one you like better. If you already offer estimates, be sure to review your current procedures and align them with new requirements.
Implementation of the No Surprises Act is in its infancy, and more guidance on the matter is expected in the future. In the meantime, it’s worth it to review the guidance already available directly from CMS. The following links are a great place to start:
​
HHS PPDR Providers Guidance (cms.gov).  
Good Faith Estimates FAQ 12.21.2021 FINAL (cms.gov)
CMS website

Sources:
[1] PUBL260A.PS (congress.gov) Title I of Division BB of the Consolidated Appropriations Act, 2021

[2] “High level overview of No Surprises Act provider requirements”, Accessed 15feb2022 online at https://www.cms.gov/files/document/high-level-overview-provider-requirements.pdf

[3] “High level overview of No Surprises Act provider requirements”, Accessed 15feb2022 online at https://www.cms.gov/files/document/high-level-overview-provider-requirements.pdf

[4] “Surprise! It's the No Surprises Act” National Law Review, Volume XI, Number 292. October 19, 2021. Accessed online at https://www.natlawreview.com/article/surprise-it-s-no-surprises-act