The No Surprises Act is a federal law enacted in 2020 to protect patients from unexpected medical bills, commonly referred to as unexpected billing or balance billing. The provisions took effect on January 1, 2022, and have since governed health care practices nationwide.
Understanding the No Surprises Act
Surprise billing happens when a patient gets care from a provider or facility that is outside their network, and then is billed for the costs that their insurance does not cover.
Note: Copays, coinsurance, and deductibles are not surprise bills. This is true unless out-of-network costs are higher than in-network limits.
The purpose of the No Surprises Act is to provide transparency to all parties involved in billing while ultimately protecting patients from financial fraud. Aside from select cash-only or nontraditional health care practices, nearly all care facilities are legally mandated to comply with this law.
An overview of the law is as follows:
- The law bans balance billing for out-of-network emergency care. This includes care given in hospital emergency departments and independent freestanding emergency departments. It also applies to care after stabilization. This continues until the patient can agree to be safely moved to an in-network facility.
- It also bans balance billing for scheduled out-of-network services. Examples include services from radiologists, pathologists, and anesthesiologists. It applies when the health care provider has not notified the patient or obtained consent.
- Insurers cannot assign higher deductibles or costs to patients for out-of-network care compared to in-network care. They must notify and get consent from patients first.
- The law provides similar patient protections for air ambulance services, but not ground ambulances.
How It Works for Emergency Physicians
The act directly impacts all emergency departments, from hospital-owned ERs to urgent care clinics.
Billing can differ if:
- The provider bills the insurer, not the patient.
- Patients only pay their in-network cost-sharing. This is based on the Qualified Payment Amount (QPA), which is the median in-network rate in their area.
- Balance billing is prohibited.
Post-Stabilization Services: What You Need to Know
The No Surprises Act does not alter your responsibilities under EMTALA. All existing requirements for the medical screening exam and stabilization remain in effect.
Expanded Protections Under the No Surprises Act
The No Surprises Act does extend balance billing protections beyond the point of stabilization. Patients cannot be balance billed for out-of-network care received:
- During the emergency visit, through stabilization or
- After stabilization, if they are admitted to your hospital, transferred to another facility via emergency medical transport, or placed in observation.
When Balance Billing Protections End
Balance billing protections may end after stabilization in either of the following situations:
- The patient is discharged.
- In your clinical judgment, the patient could safely transfer to an in-network facility via non-emergency transportation. Or, additionally, if the patient receives and signs a consent form from the receiving provider.
Compliance Requirements for Health Care Providers
Compliance is essential to prevent medical board investigations. Below are several criteria required by health care providers under the No Surprises Act.
- Limit the amount they bill consumers for out-of-network care in certain situations.
- Follow the notice and consent guidelines in order for a consent to be valid
- Take steps to promote transparency.
- Tell consumers about their right to receive a good faith estimate.
- Provide a good faith estimate.
- Refrain from moving certain bills into collections.
Violation of such requirements can result in fines, and for repeat offenses, potential federal sanctions. Furthermore, physicians may be terminated from contracted hospitals or removed from participation in insurance networks.
Practical Tips for Providers
- Conduct a Compliance Audit: Review current billing and disclosure practices.
- Update Policies and Train Staff: Provide legal updates, scripting for patient conversations, and documentation processes.
- Use Legal Counsel Proactively: Assess risk, handle disputes, and negotiate with payers.
Speak to a Health Care Attorney Today
The No Surprises Act can have far-reaching effects for physicians, potentially harming their practice indefinitely. Proactive legal counsel from a health care law firm can help assess risk and ensure best practices remain aligned with state and federal legislation. If you’re unsure how these rules apply to your practice, it’s important to consult with a health care law attorney who understands the nuances of No Surprises Act compliance.
Much is a leading choice for health care providers. We help you stay compliant with all the changing laws, providing tailored advice to ensure your policies meet legal standards. Reach out to your Much attorney to get the support your practice needs to stay compliant, and if needed, resolve disciplinary matters effectively.