Understanding the No Surprise Billing Act

The No Surprise Billing Act is a law designed to protect patients from unexpected medical bills. It prohibits health care providers from charging patients more than the amount their insurance company pays for out-of-network care.

The law applies to emergency services, including hospital stays, surgeries, and ambulance rides. This means that patients can't be charged more than the in-network cost-sharing amount for emergency care.

Patients who receive emergency services from out-of-network providers will be protected from surprise medical bills. This protection extends to patients who are transferred to an out-of-network hospital or facility during an emergency.

The No Surprises Act is a federal law that protects consumers from surprise medical bills. It was enacted as part of the Consolidated Appropriations Act of 2021 on December 27, 2020. The law creates new requirements for health insurance plans, healthcare providers, and facilities regarding balance billing, notice and consent, and disclosures about balance billing protections.

The No Surprises Act aims to prevent unexpected medical bills from out-of-network providers or facilities. This can happen when a patient receives care from an out-of-network provider or facility without knowing it, or when a provider bills a patient for the difference between their charges and the insurance company's payment.

Balance billing occurs when a healthcare provider bills a patient for the difference between their charges and the insurance company's payment. This can happen when a patient receives care from an out-of-network provider or facility. In-network providers agree not to balance bill, but out-of-network providers may do so.

The No Surprises Act prohibits balance billing in emergency situations, including air ambulances, and non-emergency services at in-network facilities. This means that a facility or provider may not bill a patient more than their in-network cost-sharing amount for emergency services.

Here are the key protections offered by the No Surprises Act:

If you think the protections have not been applied correctly, you can file an appeal with your insurance company or request external review of the company's decision. You can also file a complaint with the federal Department of Health and Human Services.

Surprise billing, also known as balance billing, is a type of unexpected medical bill that can happen when you receive care from a provider or facility outside of your health insurance network.

A surprise bill can occur when you unknowingly get medical care from a provider or facility outside of your insurance network, leaving you with unexpected costs.

This can happen even if you're receiving emergency care, as one in five emergency room visits resulted in a surprise medical bill before the No Surprises Act was implemented.

The No Surprises Act bans balance billing for emergency services and some non-emergency services, including air ambulance services from out-of-network providers.

Emergency services must now be covered without any prior authorization, regardless of whether or not a provider or facility is in-network.

If you go to an in-network hospital or ambulatory surgical center for non-emergency care, balance billing isn't allowed for certain ancillary services, such as:

To protect yourself from surprise billing, it's essential to understand your rights and the protections provided by the No Surprises Act.

The No Surprises Act provides crucial protections for patients. As of January 1, 2022, surprise bills are not allowed for covered emergency out-of-network services, including air ambulance services.

Patients are protected from surprise bills for non-emergency services performed by an out-of-network provider at an in-network facility. An out-of-network provider may not bill you more than your in-network copays, coinsurance, or deductibles for covered services performed at an in-network facility.

To receive a balance bill, an out-of-network provider must meet specific requirements, including giving you a plain-language explanation of your rights and obtaining your written consent.

Here are the specific protections in place:

You have the right to waive your rights under the No Surprises Act, but only under limited circumstances. This means you can't just opt out of your protections whenever you want.

Providers can refuse to give you care if you refuse to give consent to waive your NSA protections. However, this is only allowed in specific situations, like when you choose to see an out-of-network provider despite in-network options being available.

You must give consent to waive your NSA rights at least 72 hours in advance of a scheduled procedure when possible. This gives you time to think about your decision and make an informed choice.

There are some situations where you can't be asked to waive your consent, like if you're impaired or unable to make an informed decision. In these cases, providers must respect your rights and not try to get you to sign away your protections.

Here are some scenarios where you can't be asked to waive your consent:

In these situations, your provider must respect your rights and not try to get you to sign away your protections.

As of January 1, 2022, consumers have new billing protections when getting emergency care from out-of-network providers at in-network facilities, including ancillary services such as x-ray, drug, laboratory, or other services.

The No Surprises Act bans balance billing for emergency services and some non-emergency services. This means that your insurance has to cover emergency services as in-network with no prior authorization, and balance billing isn't allowed for emergency care, even at out-of-network hospitals, emergency departments, or air ambulance companies.

You can't be asked to waive your protections and agree to pay more for out-of-network care at an in-network facility. A facility can't ask you to pay more for care related to emergency medicine, anesthesiology, pathology, radiology, or neonatology — or for services provided by assistant surgeons, hospitalists, and intensivists, or for diagnostic services including radiology and lab services.

If you go to an in-network hospital or ambulatory surgical center for non-emergency care, balance billing isn't allowed for certain ancillary services, including anesthesiology, pathology, radiology, or neonatology, care from assistant surgeons, hospitalists, or intensivists, diagnostics like radiology or laboratory services, and any other item or service from an out-of-network provider if an in-network provider wasn't available.

Here are some examples of protected services:

Note that balance billing isn't allowed for these services, and your insurance will cover them as in-network with no prior authorization.

If you're paying for services yourself, you have the right to a good-faith cost estimate from the provider, which can help you challenge a bill if it's significantly higher than expected.

If a provider bills you $400 or more above the estimate, you can dispute the bill. This can be a huge relief if you're not insured.

To calculate the cost-share for patients, the recognized amount is used, which is the median of a plan's contracted rates on January 31, 2019. This amount is considered the qualifying amount for the service rendered.

If you're using insurance, your insurer can tell you what's covered and estimate your out-of-pocket costs. If your insurer denies a claim, you can dispute that decision and work towards a resolution.

Arbitration is also available to resolve disputes between providers and insurers, which means you don't have to be involved in negotiations. If they disagree over a payment, they can either work it out themselves or use the new arbitration process.

Disputes Over Debt can be a real challenge. If you're paying for services yourself, you have the right to a good-faith cost estimate from the provider.

If a provider bills you $400 or more above that estimate, you can challenge the bill. This is a crucial step in disputing a debt, and it's essential to know your rights.

You can also dispute a bill if your insurer denies a claim because it says certain services aren't covered. Your insurer can tell you what's covered and estimate your out-of-pocket costs.

Here are some key facts to keep in mind:

Changes to Workflow have been implemented to ensure compliance with the No Surprises Act. Providers can no longer bill patients more than the applicable in-network cost-sharing amount, with a penalty of up to $10,000 assessed for each violation.

The billing process has changed significantly. Providers must now find out the patient's insurance status and submit the out-of-network bill directly to their insurance plan.

To do this, providers must include all applicable information regarding whether NSA protections apply to the claim and whether the patient has consented to waive their protections.

Health plans must respond within 30 days, advising the provider of the applicable in-network amount for the claim in question, along with an initial payment.

Here's a breakdown of the steps involved in the new billing process:

Providers and payers must also identify bills protected by the No Surprises Act and disclose applicable protections to patients, both on their website and on an individual basis to patients that receive services covered by the law.

Arbitration Between Providers and Insurers is a process that helps resolve out-of-network bills without adding extra costs to patients. This means you won't need to get involved in negotiations or disputes between providers and your insurer.

The No Surprises Act provides a fair process for insurance companies and health care providers to resolve disagreements over payments. They have to work it out themselves or use a new arbitration process to find a solution.