Surprise-Free Solutions: Understanding The Intersection Of Insurance And Surprise Bill Laws

Surprise billing, sometimes referred to as balance billing, occurs when patients receive care from an out-of-network provider or facility and are charged additional fees not covered by their insurance provider. To protect patients from these unexpected and often costly bills, the No Surprises Act was implemented in 2022, prohibiting this practice in certain circumstances. This federal law ensures that patients are only responsible for in-network cost-sharing amounts in most emergency services, even if they are treated by an out-of-network provider. Additionally, it protects patients from surprise billing for certain services at in-network facilities, such as air ambulance services provided by out-of-network providers. The law also includes a dispute resolution process, allowing providers and insurance companies to negotiate payment amounts while keeping patients out of the middle. This legislation is a significant step forward in protecting patients from unexpected financial burdens and ensuring they can access the care they need without fear of excessive charges.

Sure! Here is a table with the characteristics and values of surprise billing as of May 24, 2024, based on a quick Google search:

Please note that surprise billing laws and their specific characteristics can be complex and may vary based on your location and insurance plan. This table provides a general overview, and further details can be found on official government websites and resources.

Patients' rights to a good faith estimate

The No Surprises Act, which came into effect on January 1, 2022, protects patients from surprise or balance billing. This is when patients receive unexpected bills from out-of-network providers or facilities, which their insurance may not cover. The Act ensures that patients have a right to a Good Faith Estimate (GFE) of the cost of their care upfront before their visit. This estimate must be provided in writing and must include the expected total cost of any non-emergency items or services, including related costs like prescription drugs, equipment, and hospital fees.

Under the Act, health care providers are required to give patients who don't have insurance or who are not using their insurance an estimate of the bill for medical items and services. This is to ensure that patients are aware of the potential costs they may incur and can make informed decisions about their care. Patients have the right to receive this Good Faith Estimate before scheduling a medical item or service and must be provided within three business days of the patient's request. It is important to note that the GFE is not a perfect estimate, but it should account for foreseeable charges.

If patients receive a bill that is at least $400 more than their Good Faith Estimate, they have the right to dispute the bill through a specific process outlined in the No Surprises Act. This process involves a third-party arbitrator reviewing the good faith estimate, the final bill, and any other relevant information submitted by the provider or facility. Patients can also contact the Patient Accounts office or the HHS No Surprises Help Desk to resolve any billing issues or disputes.

The No Surprises Act 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. This helps to ensure that patients are not left with unexpected or excessive medical bills. Overall, the Act aims to provide patients with accurate information regarding their expected healthcare spending and protect them from unexpected financial burdens.

Protection from balance billing

The No Surprises Act, which came into effect on January 1, 2022, protects patients from surprise or balance billing. This occurs when a patient receives a bill for the difference between the charges billed by an out-of-network provider and the amount paid by the patient's health plan. This can happen when a patient receives emergency care or is treated by an out-of-network provider at an in-network hospital.

The No Surprises Act protects people with group or individual health insurance plans from receiving surprise medical bills when they receive 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.

Under the Act, patients are protected from balance billing for emergency services from out-of-network providers or facilities without prior authorization. Out-of-network cost-sharing for emergency and some non-emergency services is also banned, meaning patients cannot be charged more than in-network cost-sharing for these services.

Additionally, out-of-network charges and balance bills for certain additional services, such as anesthesiology or radiology, provided by out-of-network providers as part of a patient's visit to an in-network facility, are prohibited. Patients must also be provided with a notice explaining their billing protections and their right to consent to waive these protections.

For uninsured or self-pay patients, the Act ensures they receive a good faith estimate of how much their care will cost before receiving treatment. If the final bill is at least $400 higher than the good faith estimate, they can dispute the charges.

The No Surprises Act provides important protections for patients, ensuring they are not burdened with unexpected and excessive medical bills, especially in emergency situations where they have little choice over their care providers.

Dispute resolution processes

The NSA establishes an independent dispute resolution (IDR) process for payment disputes between plans and providers. This process is designed to be a last resort if all other plan-provider negotiations fail. It incentivizes both parties to make reasonable offers, as one of the two offers will be selected by a third-party arbitrator. The losing party is responsible for the IDR fees, which can range from $350 to $700 for single determinations.

The process for initiating a dispute varies depending on the state and the type of insurance coverage. For example, in New York, if you have health insurance coverage subject to NY Law, you can submit a dispute through the IDR process for surprise bills for emergency services. You must sign a Surprise Bill Certification Form and send it along with a copy of the bill to your health plan and provider. If you have employer/union-self-funded coverage, you may be eligible to file an IDR through New York State or through the Federal No Surprises Act.

In California, the Independent Dispute Resolution Process (IDRP) allows non-contracting individual health professionals who provided non-emergency services in a contracted health facility to contest a payment amount. Providers can submit a request for a binding IDRP to the California Department of Insurance using the IDRP Request Form.

It is important to note that the rollout of the independent dispute resolution process has been challenging due to a higher-than-expected volume of disputes, with 61% of disputes remaining unresolved as of June 2023. However, the process still offers a valuable mechanism for resolving payment disputes between plans and providers.

Requirements for health plans

The No Surprises Act (NSA) protects consumers covered under group and individual health plans from receiving surprise medical bills. The law requires private health plans to cover surprise medical bills for emergency services, including air ambulance services, as well as out-of-network provider bills for services rendered at in-network hospitals and facilities.

Under the NSA, health plans must:

• Ban surprise bills for most emergency services, even if they are 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. Consumers cannot 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 consumers an easy-to-understand notice explaining the applicable billing protections, who to contact if there are concerns that a provider or facility has violated the protections, and that patient consent is required to waive billing protections (i.e., consumers must receive notice of and consent to being balance billed by an out-of-network provider).
• Provide an advanced explanation of benefits. Consumers can request advance information about how services will be covered before they are provided. For scheduled services, consumers can submit requests and, generally within three business days, the health plan must provide written information including whether the provider/facility is in-network, and a good faith estimate of what the plan will pay and what patient cost liability may be.
• Provide transitional continuity of coverage when a provider leaves the network. Health plans must notify enrollees when a provider/facility leaves the plan network while it is providing ongoing care. In certain cases, health plans must also provide transitional coverage for up to 90 days or until treatment ends (whichever is earlier) at in-network rates. The transitional coverage requirement applies to treatment for serious or complex health conditions, institutional or inpatient care, non-elective surgery, pregnancy, and care for patients with terminal illness.
• Maintain accurate provider network directories. Health plans and issuers must establish a verification process to update provider directory information at least every 90 days. They must also respond within one business day to requests from individuals about whether a provider or facility is in-network. This information becomes binding. Consumers who rely on incorrect information conveyed by plans or posted in directories are entitled to have services covered with in-network cost-sharing applied. Providers and facilities are also required to provide timely updates to health plans when the content of their directory information changes.
• Disclose information about broker commissions. Individual health insurance plans, including short-term limited duration insurance, must disclose to enrollees the amount of direct and indirect compensation paid to brokers for that enrollment. Plans must also report information on broker compensation annually to the Secretary. This disclosure must be made before the individual finalizes plan selection. Disclosure of broker and consultant commissions is also required for group health plans.

Protections for uninsured patients

Surprise medical bills are unexpected bills from an out-of-network provider or facility. These bills can arise in emergencies when patients have little or no say in where they receive care, or in non-emergencies when patients at in-network hospitals receive care from out-of-network ancillary providers (such as anesthesiologists) whom they did not choose.

The No Surprises Act (NSA), which came into effect on January 1, 2022, provides protections for uninsured patients. Under the NSA, uninsured patients are entitled to receive a "good faith" estimate of how much their care will cost before they receive it. This estimate must include expected charges for the primary item or service, as well as any other items or services that would reasonably be expected. For example, for a surgical procedure, the estimate should include the cost of surgery, as well as any labs, other tests, and anesthesia that might be used.

If an uninsured patient receives a bill that is at least $400 more than the good faith estimate, they may be able to dispute the charges through the new dispute resolution process. This process uses a third-party arbitrator to review the good faith estimate, the final bill, and any other information submitted by the provider or facility to determine the final payment amount.

In addition to the NSA, there are also state-level protections against surprise medical bills. For example, California law protects consumers from surprise medical bills when they receive non-emergency services at an in-network facility and receive care from an out-of-network provider without their consent. Under this law, consumers are only required to pay their in-network cost-sharing and medical providers are prohibited from sending consumers out-of-network bills.

Frequently asked questions