Understanding The Surprise Bill Law: Unraveling The Insurance Maze

Surprise medical bills are a leading cause of affordability concerns for many families. In fact, 2 in 3 adults worry about unexpected medical bills, more than the number worried about affording other healthcare or household expenses. These bills arise in emergencies when patients have little to no say in where they receive care, or when patients at in-network hospitals or other facilities receive care from out-of-network ancillary providers (such as anesthesiologists) whom they did not choose.

In the US, the No Surprises Act (NSA) was enacted in 2020 to provide new federal consumer protections against surprise medical bills. The Act 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, and services from out-of-network air ambulance service providers. It also establishes an independent dispute resolution process for payment disputes between plans and providers.

The No Surprises Act (NSA) protects people with private health insurance from surprise medical bills

Surprise medical bills are unexpected bills from out-of-network providers or facilities. This can happen when patients receive emergency treatment and are unable to "shop around", or when they are treated by out-of-network providers at in-network facilities. In the past, a patient's health plan may not have covered the entire out-of-network cost, leaving them with higher costs than if they had received care from an in-network provider. This is known as "balance billing".

The NSA 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. It also requires health care providers and facilities to give patients an easy-to-understand notice explaining the applicable billing protections, who to contact if they have concerns that their rights have been violated, and that patient consent is required to waive billing protections.

The NSA will protect consumers from surprise medical bills by requiring private health plans to cover out-of-network claims and apply in-network cost-sharing. It prohibits doctors, hospitals, and other covered providers from billing patients more than the in-network cost-sharing amount for surprise medical bills, with a penalty of up to $10,000 for each violation. It also establishes a process for determining the payment amount for surprise, out-of-network medical bills, starting with negotiations between plans and providers and, if negotiations don't succeed, an independent dispute resolution (IDR) process.

The NSA also protects those without insurance or who choose to self-pay

The No Surprises Act (NSA) provides protections for uninsured individuals or those who choose to self-pay for insurance.

Under the NSA, uninsured or self-paying patients are entitled to a "good faith" estimate of the costs of their care before receiving treatment. This estimate must be provided within 1 business day of scheduling a service that is planned at least 3 business days ahead of time, within 3 business days of scheduling a service that is planned at least 10 business days ahead of time, or within 3 business days of a patient requesting an estimate. The good faith estimate must include a description of the service, a list of other services that are expected to be provided, the diagnosis and expected service codes, and the expected charges for the services.

If the final bill exceeds the good faith estimate by at least $400, patients are entitled to dispute the charges. This dispute must be initiated within 120 days of receiving the bill. The NSA establishes an independent dispute resolution process for uninsured and self-pay individuals to resolve payment disputes.

The NSA establishes an independent dispute resolution process for payment disputes

Surprise medical bills are a leading cause of affordability concerns for consumers. These unexpected bills arise in emergencies when patients have little to no say in where they receive care. They can also arise in non-emergencies when patients at in-network hospitals or other facilities receive care from out-of-network providers.

The No Surprises Act (NSA) establishes new federal protections against surprise medical bills. The NSA protects patients 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, and services from out-of-network air ambulance service providers.

The NSA establishes an independent dispute resolution (IDR) process by which entities decide certain payment disputes between physicians and payers that qualify as surprise billing situations under the NSA. The IDR process is managed by the Department of Health and Human Services, the Department of Labor, and the Department of the Treasury.

The IDR process works as follows:

• When a provider or facility gets a payment denial notice or an initial payment from a health plan for certain out-of-network services, the health plan, provider, or facility must start an open negotiation period that lasts 30 business days.
• At the end of the negotiation period, if the health plan and provider or facility have not agreed on a payment amount, either party can begin the IDR process within 4 business days.
• The disputing parties have the option to choose a third-party entity, known as a certified IDR entity, from a list of certified organizations to resolve their dispute.
• The provider or facility and the health plan or issuer must submit payment offers and additional information supporting their payment offers to the certified IDR entity.
• The certified IDR entity must select from the disputing parties' payment offers. Both the provider or facility and the health plan or issuer must abide by the decision, and payment must be made within 30 calendar days.

The NSA's independent dispute resolution process provides a channel for payers and providers to negotiate payments without affecting patient spending. It is now a core element of payment negotiation in the healthcare system.

The NSA requires health care providers to give patients an easy-to-understand notice explaining their rights

Surprise medical bills are unexpected bills from out-of-network providers or facilities. These bills arise in emergencies or when patients at in-network hospitals or facilities receive care from out-of-network providers.

The No Surprises Act (NSA) protects consumers from surprise medical bills and requires health care providers to give patients an easy-to-understand notice explaining their rights. This notice must include:

• The right to request restrictions on certain uses and disclosures of protected health information (PHI)
• The right to receive confidential communications of PHI
• The right to inspect and copy PHI
• The right to amend PHI
• The right to receive an accounting of disclosures
• The right to revoke an authorization
• The right to opt out of communications and fundraising from the organization
• The right to file a complaint to the organization or the secretary of the Department of Health and Human Services (HHS)
• The right to be notified of a breach of unsecured PHI

The notice must be provided to the patient before the provider requests payment. It should be user-friendly, accessible, and easy to understand. It should be provided in plain language and translated into frequently encountered languages, such as Spanish. Alternate formats, such as large print, audio, or Braille, should be provided for patients with disabilities.

In addition to the notice, patients have the following rights:

• The right to be treated with respect, without discrimination based on age, race, ethnicity, color, religion, sex, gender identity, or sexual orientation
• The right to emergency care
• The right to obtain medical records
• The right to privacy of medical records
• The right to informed consent
• The right to refuse treatment
• The right to refuse to take part in research
• The right to receive and question itemized bills for medical services
• The right to make decisions about end-of-life care
• The right to make decisions regarding organ donation

The NSA applies to most surprise bills for specific types of services provided in certain settings

Surprise medical bills arise when insured consumers inadvertently receive care from out-of-network hospitals, doctors, or other providers they did not choose. This can happen in emergencies, when patients have little or no say in where they receive care, or in non-emergencies when patients at in-network hospitals or other facilities receive care from ancillary providers (such as anesthesiologists) who are not in-network and whom the patient did not choose.

The No Surprises Act (NSA) establishes new federal protections against surprise medical bills that took effect on January 1, 2022. The NSA applies to most surprise bills for specific types of services provided in certain settings.

The NSA's protections will apply to most surprise bills for emergency services, including those provided in hospital emergency rooms, freestanding emergency departments, and urgent care centers that are licensed to provide emergency care. The federal law also applies to air ambulance transportation (emergency and non-emergency) but not ground ambulance services. Emergency care includes screening and stabilizing treatment sought by patients who believe they are experiencing a medical emergency or active labor.

The NSA also covers non-emergency services provided by out-of-network providers at in-network hospitals and other facilities. The federal government estimates that 16% of 11.1 million (or about 1.8 million) in-network non-emergency facility stays for privately insured patients each year involve at least one out-of-network claim. The regulation defines covered non-emergency services broadly to include treatment, equipment and devices, telemedicine services, imaging and lab services, and preoperative and postoperative services, regardless of whether those services are provided within the facility itself.

The NSA defines emergency services to include post-stabilization services provided in a hospital following an emergency visit. Post-stabilization care is considered emergency care until a physician determines that the patient can be safely transferred to another in-network facility using non-medical transport, that such a facility is available and will accept the transfer, and that the transfer will not cause the patient other unreasonable burdens. The NSA also requires patients to receive written notice and give written consent to be transferred.

The NSA establishes a process for determining the payment amount for surprise, out-of-network medical bills, starting with negotiations between plans and providers and, if negotiations don't succeed, an independent dispute resolution (IDR) process.

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