No Surprises Act Enforcement Act: Consumer Rights and Protections

The No Surprises Act Enforcement Act is designed to protect consumers from surprise medical bills. This law requires out-of-network providers to give patients a clear estimate of their costs beforehand.

Patients have the right to request an estimate from their healthcare provider, and they must receive it within 3 business days. This estimate must include the expected charges for the service.

Consumers can also dispute surprise medical bills by contacting their state's Attorney General or a consumer protection agency. These agencies can help resolve disputes and ensure compliance with the law.

The No Surprises Act was created as part of the Consolidated Appropriations Act of 2021.

It established protections against out-of-network balance billing, which means patients won't receive surprise medical bills for services they didn't expect to be charged for.

Physicians and providers, facilities, and health plans can use the Independent Dispute Resolution (IDR) process to resolve payment disputes for certain out-of-network charges.

The IDR process helps determine the payment rates for those services.

The No Surprises Act provides strong protections for federal employees and their families.

The Federal Employees Health Benefits Program (FEHB) is covered under the No Surprises Act, which means that federal employees have access to the same protections as other Americans.

OPM, the Office of Personnel Management, is responsible for administering the FEHB Program and enforcing compliance with the No Surprises Act.

Health care providers, facilities, and air ambulance services must comply with certain requirements, such as disclosing their rates and network status in advance, to ensure that federal employees receive fair and transparent billing.

The No Surprises Act has brought relief to many individuals who have received surprise medical bills, also known as "balance bills."

These bills often occur when patients receive care from out-of-network providers at an in-network facility, leading to unexpected charges.

Under the FEHBA, federal employees health benefits plans are required to comply with certain provisions that protect patients from surprise medical bills.

The FEHBA has been amended to include new subsection (p), which requires carriers to comply with provisions of the PHS Act, ERISA, and Code in the same manner as they apply to group health plans or health insurance issuers.

OPM maintains oversight and enforcement authority with respect to FEHB health benefits plans, which are federal governmental plans.

For most people, federal protections apply to surprise medical bills, including those who receive care from out-of-network providers at an in-network facility.

In these cases, the health plan, physician, provider, or facility must start an open negotiation period of 30 business days to determine a payment amount.

Not all providers are created equal, and some may try to take advantage of consumers by waiving their rights. This is often the case with predatory lenders who offer short-term loans with extremely high interest rates.

Consumer rights can be waived in certain situations, such as when a consumer signs a contract that includes a waiver of their rights. This can happen when a consumer is not given a clear explanation of the waiver or is coerced into signing it.

Providers are not always required to provide consumers with a clear explanation of their rights, but the Federal Trade Commission (FTC) does require them to disclose certain information, such as the terms and conditions of a contract.

In some cases, consumers may not realize that their rights have been waived until it's too late, and they've already signed a contract. This can be a costly mistake, especially if the consumer is not aware of the potential consequences.

The FTC has guidelines in place to help consumers understand their rights and avoid being taken advantage of by unscrupulous providers. By staying informed and being aware of the potential risks, consumers can protect themselves and make informed decisions about their financial dealings.

The No Surprises Act Enforcement Act is designed to protect consumers from surprise medical bills.

The Act requires healthcare providers to give patients a clear estimate of their costs before providing treatment.

This estimate must include all charges, including facility fees, doctor fees, and any other costs associated with the treatment.

Patients have the right to request an estimate from their healthcare provider, and providers must provide it within 3 business days.

If a patient receives a surprise medical bill, they can file a complaint with their state's Attorney General's office.

The Attorney General's office will investigate the complaint and take action if necessary.

Consumers can also report surprise medical bills to the US Department of Health and Human Services.

The US Department of Health and Human Services will track and analyze the reports to identify patterns and trends.

This data will help inform policy decisions and enforcement actions to protect consumers.

The No Surprises Act (NSA) has a defined Independent Dispute Resolution (IDR) process to help settle billing disputes.

Either party can trigger the IDR process after a 30-day negotiation period. This process is meant to drive down health-care costs, help both parties negotiate a payment rate, and reduce the harms of surprise bills.

The IDR process requires the physician, provider, or facility and the health plan to submit payment offers to the dispute-resolution entity, along with additional information supporting their payment offers.

A dispute can't be started until the required 30-business-day open negotiation period has ended, and must be started within 4 business days after the open negotiation period has ended.

Here are the steps involved in the IDR process:

The dispute-resolution entity's decision is final, and all parties must abide by it. Payment must be made within 30 calendar days.

Many people have experienced receiving surprise medical bills, also known as "balance bills." These bills occur when patients unknowingly receive care from providers outside their health plan.

The No Surprises Act prohibits providers from balance billing recipients, with some case exceptions. This means that patients are protected from receiving unexpected medical bills.

Medicare and Medicaid both prohibit providers from balance billing recipients. This is a significant step towards protecting patients from surprise medical bills.

The No Surprises Act also amended the FEHBA, adding a new provision that requires FEHB Program contracts to comply with certain provisions. This ensures that federal employees and their families are protected from surprise medical bills.

If a health plan denies payment or provides an initial payment for out-of-network emergency services, an open negotiation period of 30 business days must begin.

Under the No Surprises Act, healthcare providers are required to give patients a good-faith estimate of charges for care. This estimate, known as a Good Faith Estimate (GFE), must be provided to uninsured or self-pay patients, who are individuals enrolled in a health plan but won't submit a claim.

The GFE is a notification outlining expected charges for a scheduled or requested item or service. CMS has provided instructions and a sample good-faith estimate template that healthcare providers must follow.

If you're an uninsured or self-pay patient, you have the right to request a GFE from your healthcare provider. They must provide it within three business days of your request.

The GFE timeframes are as follows:

For instance, if you schedule a procedure at least 10 business days in advance, your healthcare provider must give you a GFE no later than three business days after scheduling.