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What does the new No Surprises Act Mean for You?

Posted by Doris Dike | Jan 21, 2022 | 0 Comments

The No Surprises Act, is a federal law that protects people covered under group and individual health plans from receiving surprise medical bills when:

·       they receive most emergency services

·        non-emergency services from out-of-network providers at in-network facilities

·       services from out-of-network air ambulance service providers

·        It also establishes an independent dispute resolution process for payment disputes between plans and providers

·        and 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 the provider. 

What are surprise medical bills?

Before the act, if patient had health insurance and received care from an out-of-network provider or an out-of-network facility, even unknowingly, the patient's health plan may not have covered the entire out-of-network cost. This could leave a patient with higher costs than if the patient got care from an in-network provider or facility. In addition to any out-of-network cost sharing the patient might have owed, the out-of-network provider or facility could bill the  patient for the difference between the billed charge and the amount the patient's health plan paid, unless banned by state law. This is called “balance billing.” An unexpected balance bill from an out-of-network provider is also called a surprise medical bill.

What are the new protections for patients?

If  a patient gets health coverage through their employer, a Health Insurance Marketplace, or an individual health insurance plan a patient purchase directly from an insurance company, these new rules will:

  • Ban surprise bills for most emergency services, even if a patient got them out-of-network and without approval beforehand (prior authorization).

  • Ban out-of-network cost-sharing (like out-of-network coinsurance or copayments) for most emergency and some non-emergency services. Patients can't be charged more than in-network cost-sharing for these services.

  • Ban out-of-network charges and balance bills for certain additional services (like anesthesiology or radiology) furnished by out-of-network providers as part of a patient's visit to an in-network facility.

  • Require that health care providers and facilities give the patient an easy-to-understand notice explaining the applicable billing protections, who to contact if a patient has concerns that a provider or facility has violated the protections, and that the patient consent is required to waive billing protections (i.e., patient must receive notice of and consent to being balance billed by an out-of-network provider).

Challenges from Providers

·      The American Hospital Association, AMA, Renown Health, UMass Memorial Health Care Inc. and two physicians based in North Carolina jointly filed suit against HHS, the Office of Personnel Management and the departments of Labor.  

·      In a separate complaint, the American Society of Anesthesiologists, American College of Emergency Physicians and American College of Radiology also filed suit against these departments. Moreover, the American Academy of Orthopaedic Surgeons issued a letter to HHS and the departments of Labor and Treasury.

·      The providers issue surrounds how HHS implemented the bill.

·      The rule provides an internal dispute resolution process (IDR) to resolve payment rates between provider and payer. 

·      The arbitrator must select the offer closest to the qualifying payment amount. Under the rule, this amount is set by the insurer, giving the payer an unfair advantage, according to the lawsuit. 

·      The provider organizations want a declaration that HHS and other federal departments acted unlawfully in requiring IDR entities to have a presumption in favor the qualifying payment amount, and they want an order vacating the rule's provisions

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