Skip to Main Content

The No Surprises Act is not a new law, but there are still some questions about how it applies to urgent care. In this blog, we clarify some confusion about good faith estimates and out of network protection. We’ll also give you ways to combat the online CEO Smishing threat to your medical practice and cover what you should know about treating COVID-19 patients with monoclonal antibodies and coding the encounters accurately.

Does the No Surprises Act Apply to Your Practice?

The No Surprises Act (NSA) established new federal protections for consumers against surprise medical bills and balance billing, most of which took effect January 1, 2022. Under the act, clinicians providing non-emergency care are required to provide good faith estimates of services when care is scheduled at least 72 hours in advance or upon request from individuals who are under self-pay.

Does this, and do other requirements of the NSA apply to your urgent care practice?

Every practice has to make that decision for themselves. Experity recommends checking with your healthcare attorney or compliance professional. The following are a couple of things to consider.

Two provisions of the federal NSA have been implemented thus far. More provisions will follow.

Good Faith Estimate (GFE) – This applies to uninsured and self-pay patients. Self-pay is defined as patients that are insured but have chosen not to bill their insurance. A GFE is required if the patient schedules three days or more in advance of their appointment. A patient can dispute if the patient receives a bill that is at least $400 more than the expected charges provided in the GFE. There are very specific guidelines as to how a dispute is filed. A Patient-Provider Dispute Resolution (PPDR) must be filed using the federal Independent Dispute Resolution (IDR) portal. At that point, your practice would need to stop all collection efforts until the dispute is resolved.

However, since most urgent care do not schedule in advance, GFE does not apply.

Out-of-Network Protections – This protects patients from medical bills for out-of-network (OON) care received at an in-network facility. An urgent care is not classified as a facility unless they are licensed to provide emergency services. The physician office setting is not included. Again, there are specific forms and processes in place that patients must follow to dispute their bill under this provision. OON protections only apply to federally regulated health plans (i.e., ERISA, ACA) or commercial health plans that are regulated by the state in a state that either does not have a surprise billing law or a state that has a surprise billing law that does not apply to this specific scenario that the NSA would otherwise protect.

States are also adopting similar laws on this topic that may be more restrictive. This is a topic your practice should monitor as part of your compliance plan.

Get the details from CMS here.

Don’t Take the CEO Fraud Smishing Bait

CEO Fraud scams targeted at personal phones (AKA: smishing) and personal email addresses are increasing. These scans tend to target new employees that are more likely to fall victim to such a scam. Due to the attacks being targeted at personally managed phone numbers and email addresses, there’s very little your company’s security team can do to prevent these, and since numbers change frequently, they are hard to block. They can be identified by checking for an unusual email address.

What is CEO Fraud?

CEO Fraud is a scam in which cybercriminals spoof company email accounts and impersonate executives to try and fool an executive team member, administrative assistant, an employee in accounting, or HR into executing unauthorized wire transfers, or sending out confidential tax information, cash, gift cards, etc.

What is phishing?

Phishing is a cybercrime in which a target or targets are contacted by email, telephone or text message by someone posing as a legitimate institution to lure individuals into providing sensitive data such as personally identifiable information, banking and credit card details, and passwords.

The information is then used to access important accounts and can result in identity theft and financial loss.

What is smishing?

Smishing is a form of phishing that uses mobile phones as the attack platform. The criminal executes the attack with an intent to gather personal information, including social insurance and/or credit card numbers. Smishing is implemented through text messages or SMS, giving the attack the name “SMiShing.”

If you receive a questionable email, do not reply and immediately delete the message.

Commercial Distribution of COVID-19 Monoclonal Antibody Therapy

On 08/15/2022, Eli Lilly started commercial distribution of the COVID-19 monoclonal antibody therapy Bebtelovimab, 175 mg.

Practices that perform monoclonal antibody therapy will need to make sure their fee schedule is set up correctly as they have not been charging for the government-supplied product. Clients may have government-supplied and commercially distributed products for a time. Take care to make sure only the commercially distributed products are billed to insurance. Batch #D534422 is the first batch number for the commercial product.

Coding remains:

  • Q0222: Injection, 175 mg for the product
  • M0222: Intravenous injection, includes injection and post administration monitoring
  • M0223: Intravenous injection, includes injection and post administration monitoring in the home or residence; this includes a beneficiary’s home that has been made provider-based to the hospital during the covid-19 public health emergency

The Average Wholesale Price (AWP) for Bebtelovimab is $2394.00.

Payer Updates

Florida Medicaid Provider Minimum Wage Requirements

On June 2, 2022, Governor DeSantis signed the “Freedom First Budget” for Fiscal Year 2022-2023 to increase the minimum wage for employees providing direct care and independent contractors of Medicaid providers to at least $15.00 an hour.

This new law requires that AHCA enter into a Supplemental Minimum Wage Agreement with each affected Medicaid provider no later than October 1, 2022.  Your practice may have received a letter from AHCA to attest under penalty of perjury that every employee of the Medicaid provider, as of October 1, 2022, will be paid at least $15.00 per hour.

Providers that do not sign will be subject to recoupment of funds associated with the minimum wage requirement. Additionally, beginning January 1, 2023, a direct care employee of a Medicaid provider that is not receiving a wage of at least fifteen dollars ($15) per hour may bring a civil action in court against the Medicaid provider and is entitled to recover the full amount of any back wages unlawfully withheld plus the same amount as liquidated damages and shall be awarded reasonable attorney’s fees and costs.

Get the FAQs here.

Medi-Cal: New Provider Portal Online Gateway

Medi-Cal announced a new online gateway to electronic services called the Provider Portal. The purpose of the Provider Portal is to:

  • Access enhanced and expanded Medi-Cal services through an online self-service portal
  • Enable electronic access to Medi-Cal correspondence, such as Remittance Advice Details, previously only accessible via mail
  • Access multiple National Provider Identifiers (NPIs) in one online account

The first phase of the Provider Portal application will be available to FFS billing providers only. A letter will be mailed to the pay-to addresses of these providers with information about the Provider Portal and instructions for registering their organizations. A second letter will be mailed to these providers with a one-time security token that will be required to register.

AltaMed: Terminating Anthem Blue Cross Medi-Cal

AltaMed has terminated their Anthem Blue Cross Medi-Cal product effective 09/01/2022. Members will either transfer to another Anthem Med-Cal group or LA Care Health Plan’s Medi-Cal product.

This only affects the Anthem Blue Cross Medi-Cal product, all other products with Anthem Blue Cross will remain intact. Be sure to ask for updated insurance information and run eligibility at every visit.

UHC: New Modifier Policy

Effective 12/01/2022, United Health Care (UHC) Commercial is implementing a payment reduction for x-rays with modifiers CT, FX, and FY, similar to Medicare.

The three modifiers are dependent on the technology:

  • CT – Computed tomography services furnished using equipment that does not meet each of the attributes of the national electrical manufacturers association (NEMA) XR-29-2013 standard (15% reduction)
  • FX – X-ray taken using film (7% reduction in December; 10% as of 01/01/2023)
  • FY – X-ray taken using computed radiography technology/cassette-based imaging (7% reduction in December; 10% as of 01/01/2023)

Full details here.

BCBS TX: Midlevel Credentialing

At this time, BCBS (Blue Cross and Blue Shield) TX has two billing options for non-physician practitioners (NPP): to credential the NPPs or bill under the supervising physician with a SA modifier. The SA modifier indicates services were performed by an NPP. There is no financial incentive to bill under the supervising physician. Either method will pay at a lower rate for NPPs.

Experity is taking a proactive approach and credentialing the NPPs with BCBS TX. We recommend clients do the same in anticipation of the option to bill under the supervising physician being eliminated. This will ensure a seamless transition without payment delays.

Interested in more urgent care tips, best practices, and industry updates? Check out our August and September installments.

Interested in more? Our RCM experts use smart solutions and best practices to stay on top of revenue cycles and reimbursement.

Learn How


Sign Up for the Urgent Care Minute

Join over 20,000 healthcare professionals who receive our monthly newsletter.