No Surprises Act | DHRpro/Clarity Like Never Before

Surprise Billing and How It Affects Doctors

As a doctor in the health care field, have you heard about surprise billing? If so, does your practice know about the No Surprises Act that went into effect on January 1, 2022? If not, it should.

When a patient receives a service from a health care provider that was not in the patient’s insurance network, the patient will very likely receive a bill for that out-of-network provider’s services. This type of situation could lead to confusion and anger for the patient when they receive one bill for for charges not covered by their in-network doctors as well as another bill (or bills) from the out-of-network doctor. For the doctors involved in a particular instance of patient care (or numerous instances in a single, multi-faceted visit), it could lead to angry patients as well as non-payment and unexpected profit loss.

For example, if a patient goes to the emergency room for stomach pain and their care team discovers a heart issue that is treated by a cardiologist who is not in their network list of providers, it won’t be long before this same patient receives a bill for services done during this visit by any in-network provider as well as an additional, unexpected bill for the out-of-network cardiologist for care received during this same ER visit.

Situations like this led to the creation of the No Surprises Act.

Consumer Protection

The No Surprises Act (NSA), as part of the Omnibus Appropriations Bill, was designed to protect consumers like the one in the above hypothetical situation. The NSA protects people covered under group and individual health plans who have been charged with a medical bill (or bills) for emergency services they received as well as any non-emergent services from out-of-network providers at an in-network facility. The new bill provides a dispute resolution process for payment disputes between plans and providers. It also provides new dispute resolution opportunities for uninsured and self-pay individuals when they receive a medical bill that is substantially greater than the good faith estimate they get from a provider. With the NSA now in effect, if a consumer schedules an appointment with an out-of-network provider who works at an in-network facility, the facility must provide the consumer with a written notice that includes any possible charges the consumer might receive if they decide to keep the appointment as well as a list of in-network doctors that could provide the same services the consumer wants.^[1]

The No Surprises Act also bans:

Surprise bills for emergency services from an out-of-network provider or facility and without prior authorization
Out-of-network cost-sharing, like out-of-network coinsurance or copayments, for all emergency and some non-emergency services
Out-of-network charges and balance bills for supplemental care, like radiology or anesthesiology, by out-of-network providers that work at an in-network facility.

Safeguard Your Practice

The No Surprises Act requires that health care providers and facilities provide consumers with an easy-to-understand notice explaining the way they bill, who to contact if they have concerns that a provider or facility has violated the billing protections, and that patient consent is required to waive billing protections (i.e., they must receive notice of and consent to being balance billed by an out-of-network provider). ^[2]

For more information about the No Surprises Act, visit CMS.gov/nosurprises, or call the Help Desk at 1-800-985-3059. TTY users can call 1-800-985-3059.

Sources:
¹ The No Surprises Act Explained | The PHIA Group
² No Surprises: Understand your rights against surprise medical bills | CMS