Anytime patients, who have a group health plan or group or individual health insurance coverage, receive a bill for unexpected emergency care, nonemergency care from an out-of-network provider or facility at in-network facilities and air ambulance services from out-of-network providers. it’s considered a ‘surprise medical bill.’ In most cases, patients do not know the associated costs from an out-of-network provider or facility and consequently acquire a large amount of medical debt without notice or authorization.

Scenarios like this can cause problems for patients and providers alike. As a result, Congress decided it was time to protect consumers from these practices. The No Surprises Act (or NSA) was signed into law in 2020 and went into effect for most consumers enrolled in individual and group health insurance plans on January 1, 2022.

What is the No Surprises Act?

The No Surprises Act aims to address unexpected gaps in patients’ insurance coverage that result from surprise medical bills. It prohibits providers, facilities and service plans from balance-billing in non-emergency, emergency and air ambulance situations. It also sets up an independent dispute resolution process in the event of payment disagreements between patients and providers. Stay compliant with the No Surprises Act with ClearGage.

When was the No Surprises Act passed?

The No Surprises Act was signed into law on December 27, 2020. The Biden administration moved quickly to implement the law by issuing several interim final rules, one proposed rule and guidance. On January 1, 2022, that the NSA took full effect. The U.S. Departments of Health and Human Services, Labor and Treasury currently enforces this federal law, which means that all 50 states must fully comply.

How does the NSA protect patients?

According to ConsumerFinance.gov, the NSA “protects you from surprise billing if you have a group health plan or group or individual health insurance coverage.” The No Surprises Act 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. In addition, the No Surprises Act requires providers and facilities to issue paperwork that clearly explains these billing protections. These documents should inform patients that consent is required to waive bill protections. It should also provide contact information in the event of a violation.

According to the Centers for Medicare & Medicaid Services (CMS), there is also protection for those that are uninsured or choose to self-pay (you don’t plan to submit the claim to the health plan). It’s called a ‘good faith estimate.’ Essentially, providers must prepare an estimate outlining the medical cost PRIOR to scheduling an item or service or if you ask for one. If you want to learn more about good faith estimates, please visit the CMS website.

Who does the No Surprises Act apply to?

The NSA billing protections apply to anyone who gets their coverage through their employer (including a federal, state or local government), or through the federal marketplaces, state-based marketplaces or directly through an individual market health insurance issuer.

The rule does not apply to people with coverage through programs such as Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care or TRICARE. These programs already prohibit balance billing.

Federal protections apply to the majority of surprise bills, including:

• Most emergency services;
• Post-emergency stabilization services provided in a hospital following an emergency visit; and
• Non-emergency services provided by out-of-network providers at in-network hospitals and other facilities.

According to Kff.org, “The interim final regulation defines ‘facility’ to include hospitals, hospital outpatient departments and ambulatory surgery centers. Consumers do not have federal protections against surprise bills for non-emergency services provided in other facilities, such as birthing centers, clinics, hospices, addiction treatment facilities, nursing homes or urgent care centers. Patients seeking care at such facilities may want to ask whether doctors bill independently and whether they are in-network.”

Does the No Surprises Act apply to physician offices?

The United States Department of Health and Human Services (HHS) states that any physician or provider who is acting within the scope of practice of that provider’s license or certification under applicable State law may be subject to the No Surprises Act, but “a provider who never provides care related to a health care facility or emergency facility would generally not fall under the No Surprises Act’s ban on balance bills.”  HHS further explains that “these physicians can continue to balance bill patients if they provide out-of-network care. However, that same provider may still need to give patients a good faith estimate of expected charges before care is provided.”

Does the No Surprises Act apply to dental?

The No Surprises Act does not have much of an impact on private dental practices outside of cost transparency because dental benefits are excepted benefits, according to the Centers for Medicare and Medicaid Services. The new requirements on balance billing generally apply to items and services provided to consumers enrolled in group health plans, group or individual health insurance coverage, as well as federal employees’ health benefits plans, but not excepted dental benefit plans.

Does the No Surprises Act apply to mental health providers?

The NSA applies to behavioral and mental health providers, including psychiatrists and counselors.

However, the surprise billing ban affects behavioral health practitioners and mental health providers who work in emergency services. However, most behavioral health providers will only be affected by the requirements for good-faith cost estimates. For mental health providers serving as a private practitioner working alone or at a group practice, they and their practice must meet cost estimate requirements as laid out by the NSA.

Let ClearGage help you navigate the No Surprises Act

Our Treatment Estimation feature helps the healthcare provider with NSA compliance by sending accurate, up-front digital cost estimates to relevant patients that help meet the ‘good faith’ estimate requirements of the No Surprises Act. Request a free demo to learn more.