No Surprises Act and Medical Bills

no suprises act

Did you know more than a third of employees say the medical bills they receive after seeking care are “always or usually” a surprise? But 28% pay them anyway because they don’t want to have to deal with the insurance company.

Insurance plans cover some of the cost of medical care. What’s left over falls in the category of deductibles or co-pays, but people don’t always remember how much those are. Doctors who are not in your network may charge more than your insurance will pay. And finally, a provider may not have or give you a complete cost picture when a service is provided. These are just a few reasons why a patient receives a bill they may not have expected.

The Consolidated Appropriations Act of 2021 (CAA), passed in December 2020, includes a number of rules, called the ‘No Surprises Act,’ to help protect consumers from unexpected medical bills. It goes into effect January 1, 2022.

No Surprises Act (NSA): Part I

The No Surprises Act (CAA Title I) protects patients by banning some specific provider costs and charges. According to the National Law Review, those bans include:

  • Ban on high out-of-network (OON) cost-sharing for emergency services. If you have an emergency service from an OON provider, your health plan must treat the bill as in-network when applying cost-sharing requirements. OON providers and facilities cannot bill a participant for amounts more than the participant’s in-network cost-sharing responsibility, and this ban generally cannot be waived by the participant. However, these providers and facilities can balance-bill participants for post-stabilization services if they tell the participant upfront and obtain their approval before the service is provided to be billed for uncovered balances.
  • Ban on OON charges for ancillary care at an in-network hospital or ambulatory surgery center. If a hospital or ambulatory surgery center is in-network, a group health plan has to bill anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, and intensivist services as in-network charges when applying cost-sharing requirements. These providers cannot bill a patient more than the participant’s in-network cost-sharing responsibility, and this ban cannot be waived by the participant.
  • Ban on other OON charges without advance notice. If a hospital or ambulatory surgery center is in-network and services other than those described above are provided, a group health plan still has to treat the services as in-network when applying cost-sharing requirements. But OON providers can bill the participant any balance due for these services if they tell them upfront and get approval for balance-billing before the services are provided.

For more information, refer to the Centers for Medicare and Medicaid Services (CMS) fact sheet about this portion of the No Surprises Act.

No Surprises Act: Part II

The second part of the NSA also goes into effect on January 1, 2022. It deals with pricing transparency and payment disputes. Part II provisions include:

  • Good Faith Estimates. Health care providers and facilities have to provide a good-faith estimate of expected charges to uninsured consumers, or to insured consumers who aren’t having their health plan help cover the costs (self-paying individuals). The estimate must be provided after a patient has scheduled an item or service, or upon their request. It should include expected charges for the primary item or service and any other items or services that are provided as part of the same scheduled experience.
  • Patient-Provider Dispute Resolution. In the event an uninsured (or self-pay) individual receives a good-faith estimate but still gets a bill for an amount “substantially in excess” of the estimate, patients will have access to a dispute resolution process to figure out an appropriate payment amount. “Substantially in excess” is defined as being at least $400 more than the expected charges listed on the good faith estimate. Parties must initiate the dispute resolution process within 120 calendar days of the patient receiving the bill. Once initiated, HHS will appoint a selected dispute resolution entity (SDRE) certified under the No Surprises Act to make a payment determination within 30 business days after information about the proceedings is received.
  • External Review. The Part II Rule generally expands the scope of claims eligible for external review as established under the Affordable Care Act to include adverse benefit determinations by health plans and health insurance issuers related to No Surprises Act compliance. The Part II Rule provides examples of the types of adverse benefit determinations which are newly eligible for external review. In addition, the Part II Rule requires grandfathered health benefit plans that generally are exempt from external review requirements to provide for external review of adverse benefit determinations for claims subject to No Surprises Act protections. The Part II Rule specifies that patients in such grandfathered plans shall be permitted to access external review after exhausting applicable appeal rights under state law or under the terms of the patient’s health benefit plan coverage.

Refer to the Centers for Medicare and Medicaid Services (CMS) for more information about this portion of the No Surprises Act.

Unexpected healthcare expenses can be devastating. Both parts of the No Surprises Act aim to reduce the element of surprise and help patients to be better prepared to pay for healthcare products and services received.

Flexible Spending Accounts (FSAs) and Health Savings Accounts (HSAs) can be used to pay for a wide variety of medical expenses not covered by insurance while helping you save on taxes. For more information, talk to your benefits administrator.

DataPath, Inc. is a leading provider of technology solutions for cloud-based benefits administration.