“Surprise billing” may be an unfamiliar term, but chances are you or someone you know has experienced it. If you’ve been “surprise billed,” you have received an unexpected bill from a facility or healthcare provider. This usually happens because you’ve received medical care from a provider or facility outside your health insurance plan’s network. When that occurs, the insurance company isn’t paying, so you get the bill — definitely an unpleasant surprise.
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What is the No Surprises Act?
Under the No Surprises Act, out-of-network services are treated as if they were in-network when assessing patient cost-sharing. As a result, the No Surprises Act sets up protections that apply to most consumers who don’t receive their health coverage through federal programs, including the uninsured and those who self-pay.Â
Exceptions to the No Surprises Act
There are exceptions to who is eligible under the No Surprises Act. Specifically, the Act does not include people with coverage under the programs, which already have protections against high medical programs, including:
- Medicaid, Medicare or TRICARE
- Veterans Affairs Health Care
- Indian Health Service
The rules of the No Surprises Act apply to you if your healthcare coverage is through your employer, including local government, state and federal employers, along with those who self-pay or are uninsured. Also, if you’re insured through a multi-employer plan and/or are covered through the federal or state-based marketplace, then the protections of the No Surprises Act apply to you.
The Complications Of Medical Billing
To help everyone start adapting to new rules, the No Surprises Act rolled out in increments. The rollout began on July 1, 2021, with part one of the interim final rule, which established restrictions on surprise billing in employer-based and individual health plans. Under this provision, patients receive in-network billing rates for emergency or non-emergency services from out-of-network providers working at in-network facilities, including air ambulance services.
A second interim final rule opened for public comment on September 30, 2021. This added more protections against surprise medical billing, including:
- Establishment of a resolution process to address independent disputes regarding out-of-network payment amounts between facilities, health plans and providers
- Required good-faith estimates for services or medical items provided to uninsured or self-paying patients
- Established process for patient-provider dispute resolution
- A pathway to appeal certain health plan decisions
Lastly, on November 17, 2021, a third interim final rule set requirements for group health plans and issuers to cover prescription drugs and healthcare spending. Included are requirements governing information on the most expensive and most frequently dispensed drugs, along with information on enrollment, premiums as well as average monthly costs employees pay compared to employers.
Summary Of Changes Occurring In 2022
The No Surprises Act is a complicated piece of legislation, so to summarize it, here are the key points set to begin January 1, 2022:
- Prohibition on surprise billing for emergency services. Even when provided out-of-network, emergency services must be provided at in-network rates with no prior authorization required.
- A ban on out-of-network cost-sharing and balance billing for emergency and select non-emergency services. Consumer costs must be equivalent to in-network costs for these services. Additionally, providers must base deductible and coinsurance costs on these in-network rates.
- Ancillary care billing restrictions. Ancillary care provided by out-of-network professionals at an in-network facility cannot charge out-of-network rates or take part in balance billing.Â
What does this mean for patients?
Healthcare consumers can expect the following:
- Consumers must receive plain-language, good-faith estimates in advance before a provider can bill out-of-network charges or take part in balance billing.
- Should you receive services from out-of-network medical professionals at an in-network facility, patients will be protected against surprise billing resulting from gaps in emergency care coverage. (This includes air ambulance services.)
- Patient liability will be limited to in-network cost-sharing amounts while leaving insurers and providers a process for negotiating reimbursement.
- An independent process for dispute resolution will be established between insurers and providers should disagreements arise over reimbursement; however, the No Surprises Act does not set benchmarks for reimbursement amounts.
- Assistance in obtaining information about health care costs will be required by health plans and providers.
- Required health care cost estimates will be issued for uninsured individuals or those choosing to self-pay.
- A resolution process is provided for payment disputes involving uninsured persons or those who self-pay.
- When employer-based or individual health plans deny payment of claims, rights will expand to external review.
The more you know, the better prepared you are to adapt to the No Surprises Act. While the Act should help alleviate some financial burdens for healthcare consumers, it can create new administrative hurdles for providers. Healthcare organizations must ensure they end balance billing and be prepared to provide upfront estimates as well as good faith billing to patients.
Having robust revenue cycle management (RCM) technology in place can help you navigate changes and consistently provide excellent patient experiences. You can rely on Raintree EMR to manage the complexity of your RCM processes while also ensuring full compliance with the No Surprises Act.
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