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Keeping up with new ICD-10 Codes and legislation like the No Surprises Act can be a challenge. In this issue of Three Things to Know About RCM, Alan Ayers, President of Experity Networks will give you an overview of the No Surprises Act. We’ll also provide tips on HIPPA compliance in regard to vaccination mandates, plus share some of the latest COVID-19 updates.

What You Need to Know About the No Surprises Act

By Alan Ayers, President, Experity Networks

The “No Surprises Act,” starting in 2022, will ban out-of-network billing for emergency services, regardless of where they’re provided, and will prohibit balance billing above the patient’s out-of-pocket limits.

Specifically, the law:

  • Bans high out-of-network cost-sharing for emergency and non-emergency services
  • Limits patient cost-sharing, such as co-insurance or a deductible, to as if such services were provided by an in-network doctor and based on in-network rates
  • Requires providers and health plans provide good faith estimates for insured patients
  • Allows health plans to pay out-of-network bills at their published in-network rates
  • Requires providers to accept the payer’s in-network rates and prohibits providers from balance billing patients any amount in excess of their deductible/co-pay/co-insurance or cost-share maximums
  • When there is a disagreement on rates, allows payers to send a “good faith” payment within 30 days of billing, which if not accepted by the provider, leads to a negotiation and dispute resolution process
  • Requires health plans to include new information on insurance ID cards, including all deductibles and maximum limits on out-of-pocket costs (also when there are none)
  • Requires certain healthcare providers and facilities to make publicly available, post on a public website, and provide to individuals a one-page notice of the regulation

To be clear, urgent care centers are not explicitly addressed in the legislation leaving some gray area. The Biden administration has shown an interest in including urgent care centers under the law, proposing a “ban on surprise bills at urgent care centers licensed to perform emergency procedures.”

But…not only are urgent care centers not encouraged to provide emergency medicine procedures, in most states they’re not licensed as healthcare facilities but instead treated like physician offices.  According to some experts, the law might not apply to urgent care.

Regardless, having a contract with every major health insurance plan in your community will assure timely reimbursement at a predictable rate. It also means your urgent care center will be listed in payer directories and will give patients the confidence that their benefits will apply, and medical billing will be fair and affordable.

Experity will continue to monitor how this act impacts the urgent care industry.

Alan Ayers has 15 years of experience in urgent care, including six years with Experity, and has served as COO and CEO of hospital urgent care joint ventures, has developed over 100 urgent care centers and consulted with clients representing over 1,000 centers nationwide, is a Lifetime Member of the Urgent Care Association and is Senior Editor of The Journal of Urgent Care Medicine.


COVID-19 Vaccinations: The Intersection of HIPAA and Vaccinations

Some states are requiring COVID-19 vaccinations for healthcare workers. Federal EEO law does not prevent an employer from requiring all employees physically entering the workplace to be vaccinated for COVID-19. But if you require vaccinations, you must also offer accommodations to staff who align with provisions outlined in Title VII of the Civil Rights Act and the Americans with Disabilities Act (ADA). Some of these accommodations are face masks, social distancing, remote work options, COVID-19 testing and, in specific cases, role reassignment.

While there are many debates all across the country regarding the legality of mandates and bans on mandates, it’s important to stay on top of your state’s policies. Some are more stringent than others, and the final answer is a moving target for healthcare organizations.


It is not a HIPPA violation to ask employees to provide proof of vaccination. Employees can decide whether or not to comply with that request. But once an employer gets the data, it’s more complicated. Vaccination status data is confidential medical information (PHI) and must be handled accordingly.

As a covered entity (CE) or business associate (BA), you are privy to HIPAA — and your employees’ COVID-19 vaccination information is considered protected health information (PHI). That means the PHI falls under the HIPAA Rules’ governance.

To protect yourself, it’s a good idea to:

  • Provide advanced written disclosures to employees regarding the vaccination process
  • Provide the legitimate business reason for the vaccination process
  • Explain how you (or the group health plan) will use, store, and share (if at all) vaccination data of individual employees

Review state privacy laws as those can be much more stringent than HIPAA and could carry penalties for noncompliance. Remember, that the Centers for Disease Control and Prevention (CDC) and Occupational Safety and Health Administration (OSHA) offer advice on the best way to compile and store staff medical records, including COVID-19 vaccination files.

Resource: See the EEOC guidance at

Published in Health Information Compliance Alert – 2021; Volume 21, Number 9

Covid-19 Round-Up: Add These 3 Updates to Your Pandemic Arsenal

With the Delta variant ratcheting up the COVID-19 case numbers, the feds continue to churn out policies to cut down the spread of the virus and boost vaccination rates — and acceptance. Here’s what you should know about vaccination mandates, booster shots, and payments policies.

COVID Booster Shots – Who’s eligible

The Biden Administration’s top health experts weighed in on the value of COVID-19 booster shots in a joint statement from the Department of Health and Human Services (HHS) and Food and Drug Administration (FDA) on Aug. 18. According to the statement booster shots will fortify the original vaccinations by maximizing vaccine-induced protection and prolonging its durability.

The group intended to promote boosters for “for all Americans beginning the week of September 20 and starting 8 months after an individual’s second dose,” the release said. But the FDA pushed back, and finally decided to authorize the Pfizer BioNTech boosters for people 65 and older and other vulnerable Americans six months after completing their first two doses. As of September 29, The FDA and CDC have not fully weighed in on the Moderna and Johnson & Johnson boosters. However, according to the health experts, a forthcoming J&J COVID booster and a half-dose Moderna booster are expected in the coming months.

  1. Feds Move Forward with COVID Vaccination Mandates

Since healthcare workers are on the front lines caring for patients, it shouldn’t be a surprise that the Department of Health and Human Services (HHS) set a COVID vaccination requirement for its 25,000+ workforce—particularly those that interact with or have the potential to come into contact with patients. This includes:

  • Indian Health Services (HIS)
  • National Institute of Health (NIH)
  • S. Public Health Service Commissioned Corps
  • Department of Veterans Affairs (VA)

Healthcare workers in the nation’s more than 15,000 Medicare and Medicaid-participating nursing homes are also be required to be vaccinated

  1. CMS Revises At-Home Vaccination Payment Policy… Again

In June, CMS offered Medicare providers a financial incentive for administering at-home COVID-19 vaccinations to beneficiaries (an additional $35/dose for one person in the home). This policy has been updated, allowing healthcare providers to receive additional payments for administering vaccines to multiple residents in one home setting or communal setting of a home. According to CMS in an Aug. 24 release, the change allows “vaccine providers to receive the increased payment up to five times when fewer than ten Medicare beneficiaries get the vaccine on the same day in the same home or communal setting.”

Read CMS’ release on the change at Review Medicare COVID vaccination payment details at Find out how to enroll as a COVID-19 vaccine provider at

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

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