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The No Surprises Act (NSA) is a groundbreaking federal law that provides consumers with new protections against surprise medical bills. The NSA requires private health plans to cover out-of-network claims and apply in-network cost sharing to ensure consumers aren’t stuck with surprise medical bills. In addition, the NSA prohibits doctors, hospitals, and other covered providers from billing patients more than the in-network cost sharing amount. To settle payment disputes, the NSA establishes a negotiation process between plans and providers, followed by an independent dispute resolution (IDR) process if negotiations don’t succeed.
What Services Apply to the No Surprises Act?
The NSA protects consumers from surprise medical bills for the following services:
Emergency Services
Surprise billing protections apply to most emergency services, including those provided in hospital emergency rooms, freestanding emergency departments, and urgent care centers licensed to provide emergency care. While the federal law applies to ambulance transportation (emergency and non-emergency), the NSA doesn’t protect consumers from surprise medical bills regarding ground ambulance services. The law requires a federal advisory committee to study the issue and recommend options to protect patients from surprise bills after receiving ground ambulance services.
Post-Emergency Stabilization Services
The NSA requires patients to receive written notice and give consent before they’re transferred for post-emergency stabilization services. By requiring written patient consent, the NSA helps ensure that patients are fully informed and understand any potential risks or fees associated with their transfer. It also ensures that the transfer won’t cause any unreasonable financial burden on the patient.
Non-Emergency Services at In-Network Facilities
The NSA covers a wide range of non-emergency services, including treatment, equipment and devices, telemedicine services, imaging and lab services, and preoperative and postoperative services. This means that patients can feel secure knowing that they won’t be hit with unexpected bills for treatments they thought were covered under their health plan.
No Surprises Act Provider Prohibitions
According to the NSA, out-of-network doctors and hospitals can no longer bill patients for their full, undiscounted fee. Instead, providers must determine a patient’s insurance status and then submit the surprise out-of-network bill directly to the health plan. Then, the insurance provider must advise the healthcare provider of the applicable in-network cost sharing amount for that claim. When the health plan sends an initial payment to the provider and sends the consumer a notice of the in-network cost sharing amount owed, the out-of-network provider is allowed to send the patient a bill for no more than the in-network cost sharing amount. By prohibiting out-of-network providers from billing patients more than the applicable in-network cost sharing amount, consumers will no longer have to worry about receiving a huge bill for services they had no way of expecting. In addition, a penalty of up to $10,000 for each violation can apply if providers don’t follow the regulations.
No Surprises Act Provider Prohibitions
According to the NSA, out-of-network doctors and hospitals can no longer bill patients for their full, undiscounted fee. Instead, providers must determine a patient’s insurance status and then submit the surprise out-of-network bill directly to the health plan. Then, the insurance provider must advise the healthcare provider of the applicable in-network cost sharing amount for that claim. When the health plan sends an initial payment to the provider and sends the consumer a notice of the in-network cost sharing amount owed, the out-of-network provider is allowed to send the patient a bill for no more than the in-network cost sharing amount. By prohibiting out-of-network providers from billing patients more than the applicable in-network cost sharing amount, consumers will no longer have to worry about receiving a huge bill for services they had no way of expecting. In addition, a penalty of up to $10,000 for each violation can apply if providers don’t follow the regulations.
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No Surprises Act 2022 FAQs
How Do Consumers Know if a Bill or Claim Constitutes a Surprise Medical Bill?
It’s up to healthcare and insurance plan providers to identify bills covered under the NSA. If providers fail to properly identify a surprise bill, it’s up to the patient to recognize that NSA protections should apply and seek relief. The regulations request public comment on whether changes to federal rules governing electronic claims are needed to indicate claims where surprise billing protections apply. Providers and facilities must post a one-page disclosure notice summarizing NSA surprise billing protections on a public website and give this disclosure to each patient. Additionally, health plan providers are also required to provide consumers the disclosure notice with every explanation of benefits (EOB) that includes a claim for surprise medical bills.
How Do No Surprises Act Waivers Work?
Patients can give prior written consent to waive their rights under the NSA. However, providers aren’t allowed to ask patients to waive their rights for emergency services or certain other non-emergency services or situations. Additionally, consent must be given voluntarily and cannot be coerced, and providers can refuse care if consent is denied.
Notice and consent waivers aren’t permitted for:
- Emergency services
- Urgent medical needs that arise after non-emergent care is complete
- Services related to emergency medicine, anesthesiology, pathology, radiology, and neonatology
- Services provided by assistant surgeons, hospitalists, and intensivists
- Diagnostic services, including radiology and lab services
- Services provided by an out-of-network provider if an in-network provider isn’t available to provide that service in that facility
What Can Consumers Do in Case of Problems?
Consumers have the right to appeal health plan decisions that incorrectly deny or apply out-of-network cost sharing to surprise medical bills. While this is an important step forward, there are still limitations on consumer access to external appeal. For example, employers must contract with the external reviewer, and there are restrictions on denial notices in other languages for those with limited English proficiency. Consumers can also contact applicable federal and state enforcement entities if their provider inappropriately bills them for a service subject to the NSA.
How Will Payments for Surprise Bills Be Determined?
The NSA requires health plans to pay a fair and reasonable amount for surprise, out-of-network bills. In most cases, this amount will be close to the median rate that plans pay in-network providers in a geographic area, also known as the Qualifying Payment Amount (QPA). Patients’ cost-sharing for a surprise medical bill must be based on the QPA. However, if health plans and providers can’t agree on a payment amount, they can enter into an Independent Dispute Resolution (IDR) process that allows both parties to make their case for an appropriate payment amount and receive a decision from a neutral third-party arbiter.
No Surprises Act Summary
Coders and billers must be aware of NSA details to accurately interpret it. At Horizon Healthcare RCM, our skilled coders and billers are well-versed on the NSA regulations to ensure your patients are never surprised when they receive their bill from your facility. Contact us today to learn more about our medical billing and coding services and how we help protect your patients under the NSA.
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