Unraveling The Regulatory Web: A Guide To Understanding Insurance Billing Compliance

Insurance regulatory law governs and regulates the insurance industry and those engaged in the business of insurance. In the United States, insurance has historically been regulated almost exclusively by individual state governments. The McCarran-Ferguson Act of 1945 describes state regulation and taxation of the industry as being in the public interest and gives it preeminence over federal law. Each state has its own set of statutes and rules, with state insurance departments overseeing insurer solvency, market conduct, and requests for rate increases for coverage. However, federal influence in insurance regulation has been expanding in recent decades, with laws such as the National Flood Insurance Act of 1968 and the Dodd-Frank Wall Street Reform and Consumer Protection Act, which established the Federal Insurance Office (FIO) to monitor all aspects of the insurance sector.

The No Surprises Act protects people from unexpected medical bills

The No Surprises Act (NSA) is a federal law that came into effect on January 1, 2022, as part of the Consolidated Appropriations Act of 2021. The Act protects people from unexpected medical bills by addressing unexpected gaps in insurance coverage that result in "surprise medical bills" when patients unknowingly obtain medical services from physicians and providers outside their health insurance network.

The NSA establishes new federal protections against surprise medical bills, which are unexpected bills from an out-of-network provider or facility. This can happen when patients receive emergency services or non-emergency services from out-of-network providers at in-network facilities. Surprise medical bills can also arise when patients receive services from out-of-network air ambulance service providers.

The NSA protects people covered under group and individual health plans from receiving surprise medical bills in the following ways:

• Banning surprise bills for most emergency services, even if received out-of-network and without prior authorization.
• Banning out-of-network cost-sharing (e.g. out-of-network coinsurance or copayments) for most emergency and some non-emergency services. Patients can only be charged in-network cost-sharing for these services.
• Banning out-of-network charges and balance bills for certain additional services (e.g. anesthesiology or radiology) provided by out-of-network providers as part of a patient's visit to an in-network facility.
• Requiring health care providers and facilities to give patients an easy-to-understand notice explaining the applicable billing protections, who to contact if the patient believes their rights have been violated, and that patient consent is required to waive billing protections.

The NSA also establishes an independent dispute resolution (IDR) 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 provided by the provider.

If you don't have health insurance or choose not to use it, the NSA ensures that you will receive a good faith estimate of how much your care will cost before receiving treatment. If the final charges are at least $400 higher than the good faith estimate, you may be able to dispute the charges.

Patients can dispute bills if they're $400 more than the original estimate

In the United States, the No Surprises Act (NSA) protects patients from surprise billing and unexpected out-of-network medical bills. The NSA came into effect on January 1, 2022, and applies to most types of health insurance.

Under the NSA, if a patient's final charges are at least $400 higher than the good faith estimate, they can dispute the medical bill through the patient-provider 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. The dispute process doesn't start until a $25 non-refundable administrative fee is paid. If the dispute is decided in the patient's favour, this fee will be deducted from the amount they owe their provider.

The NSA 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 when they receive a medical bill that is substantially greater than the good faith estimate they get from the provider.

The NSA protects patients from surprise billing for emergency services if they have a group health plan or group or individual health insurance coverage. It also limits the amount of:

• Surprise bills for emergency services from an out-of-network provider or facility without prior authorization
• Out-of-network cost-sharing 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

The NSA requires providers to give uninsured or self-pay individuals a good faith estimate of how much their care will cost before they receive it. If the patient is then billed for an amount more than $400 over the good faith estimate, they can use the new dispute resolution process to determine the final payment amount.

The NSA also requires health care providers and facilities to disclose Federal and State patient protections against balance billing and sets forth complaint processes with respect to violations of the protections against balance billing and out-of-network cost-sharing.

Surprise bills are common among US residents with private health plans

Surprise bills arise in emergencies when patients have little or no say in where they receive care. They also arise in non-emergencies when patients at in-network hospitals or other facilities receive care from out-of-network ancillary providers (such as anesthesiologists) whom the patient did not choose.

Research shows that surprise bills are common among the nearly 200 million US residents enrolled in private health plans. A 2020 study found that 20% of privately insured patients who had elective surgery at a hospital that was in their insurance network received surprise bills from providers who were not.

In response to individuals receiving large, unexpected medical bills for out-of-network care, Congress passed the No Surprises Act, which took effect on January 1, 2022. The Act bans surprise billing in private insurance for most emergency care and many instances of non-emergency care. It also requires that uninsured and self-pay patients receive key information, including overviews of anticipated costs and details about their rights.

The No Surprises Act covers all privately insured people

The No Surprises Act (NSA) is a federal law that came into effect on January 1, 2022, as part of the Consolidated Appropriations Act of 2021. The Act protects all privately insured people in employer-sponsored and individual/family health plans from surprise medical bills.

A surprise medical bill is an unexpected bill from an out-of-network provider or facility. This can happen when a patient receives emergency services, non-emergency services from out-of-network providers at in-network facilities, or services from out-of-network air ambulance service providers.

Before the No Surprises Act, if a patient with health insurance received care from an out-of-network provider or facility, their health plan might not have covered the entire out-of-network cost. This could result in higher costs for the patient than if they had received care from an in-network provider or facility. In addition, the out-of-network provider or facility could bill the patient for the difference between the billed charge and the amount paid by the health plan, a practice known as "balance billing".

The No Surprises Act bans surprise bills for most emergency services, even if they are received out-of-network and without prior authorization. It also bans out-of-network cost-sharing for most emergency and some non-emergency services, as well as out-of-network charges and balance bills for certain additional services (like anesthesiology or radiology) provided by out-of-network providers at in-network facilities.

The Act limits the amount patients pay out of pocket to what they would typically pay if the healthcare provider were in-network. It defines this limit using a recognized market amount or qualifying figure, such as the average fee for the service. The Act also requires health care providers and facilities to give patients an easy-to-understand notice explaining the applicable billing protections and their rights in the event of a billing dispute.

For those without health insurance or who choose not to use it, the Act ensures they receive a "good faith" estimate of how much their care will cost before they receive it. If the final bill is at least $400 more than the estimate, they can dispute the charges.

The No Surprises Act establishes an independent dispute resolution (IDR) process to handle payment disputes between plans and providers, and provides new dispute resolution opportunities for the uninsured and self-pay individuals. It is enforced by various federal agencies, including the U.S. Department of Labor, the Department of Health and Human Services, and the Department of the Treasury, with states taking the lead in enforcing state-regulated plans.

The No Surprises Act applies to nearly all private health plans

The No Surprises Act (NSA) is a federal law that came into effect on January 1, 2022, as part of the Consolidated Appropriations Act of 2021. 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.

The NSA applies to nearly all private health plans, including job-based and non-group plans, such as grandfathered plans. It covers all privately insured people in employer-sponsored and individual/family health plans.

Under the NSA, private health plans are required to cover out-of-network claims and apply in-network cost-sharing. This means that if you have private health insurance, you are protected from surprise bills for most emergency services, even if you receive them out-of-network and without prior approval. The NSA also bans out-of-network cost-sharing for most emergency and some non-emergency services, as well as out-of-network charges and balance bills for certain additional services (e.g. anesthesiology, radiology) provided by out-of-network providers as part of a patient's visit to an in-network facility.

The Act establishes an independent dispute resolution (IDR) 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 higher than the good faith estimate they received from the provider. The good faith estimate is an estimate of how much the care will cost, which uninsured or self-paying individuals can request or receive when they schedule care in advance.

The NSA 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 about a violation of the protections, and that patient consent is required to waive billing protections.

The federal government has primary responsibility for oversight and enforcement of the NSA with respect to self-insured group health plans, which cover about half of all people with job-based coverage. The federal government will also step in if states refuse or cannot enforce the law with respect to health care providers and facilities.

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