Surprise BillingPublic concern over surprise billing practices has made new regulations inevitable. The Kaiser Foundation published a study on February 11, 2020 that showed 1 out of 5 adults received a Surprise Medical Bill in the past 2 years. The National Association of Insurance Commissioners did a poll in July of 2020, and they found that more than 60% of consumers were worried that they, or a family member, might receive a surprise medical bill that would be hard for them to pay.

Part 1 of the NSA “No Surprise Act” was released on July 1st and is the first in a series of rules to enforce and regulate surprise billing practices at the Federal level.

When does the rule take effect?

  • Consumer protections in the rule will take effect beginning on January 1, 2022
  • For Health Plans and Health Insurance carriers – plan years beginning on or after January 1, 2022
  • For FEHB program carriers – contract years beginning on or after January 1, 2022
  • For Provider and Facilities – service encounters beginning January 1, 2022

Who must abide by the Surprise Billing Guidelines?

  • Group health plans
  • Group and Individual health insurance issuers
  • Federal Employee Health Benefits Program carriers
  • Healthcare providers and facilities
  • Air Ambulance service providers
  • Employer Self-Insured plans

What is a Surprise Medical Bill?

  • When a patient receives care from an out-of-network provider, the health plan usually does not cover the entire OON cost. This leaves the patient with higher costs than if they had been seen “in-network”.
  • Often the OON provider can bill the patient for the difference between the billed charge and the amount paid by the health plan (unless prohibited by state laws). This is “balance billing, creating and unexpected or “surprise” bill to the patient

What does the No Surprises Act require?

  • The prohibition of balance billing on emergency services, ambulance services, and services rendered by “nonparticipating providers at a participating facility in certain circumstances”- for example an anesthesiologist who might be out of the patient’s network even if the facility is in network.

What do Physicians and Facilities need to know?

  • Physicians who work in the Emergency Department, in a physician office and sometimes in facilities may often treat patients out-of-network and will need to pay careful attention to these regulations.
  • Notice to patient requirements
      1. The requirements and prohibitions applicable to the provider or facility regarding balance billing.
      2. Any applicable state balance billing prohibitions or limitations.
      3. How to contact appropriate state and federal agencies if the patient believes the provider or facility has violated the requirements described in the notice.
      4. This information must be publicly available from the facility/provider
  • There will be new “advance explanation of benefits” required by the Act but not yet fully addressed in the rules.
  • The Act mandates that providers send a “good faith estimate of charges before they deliver any given health care service.” The provider will need to send this good faith estimate to the patient’s health plan within one to three days.” If the services require multiple providers, they will need to talk to each other and come up with a price and send it over to the health plan.
  • Complex procedures, such as surgeries, pose another problem as providers will have difficulty in estimating all of the possible items and services, as well as the range of different specialties and ancillary services that will provide health care. And all of this needs to be done in three days, and in some cases “within a day.”

** Part B News, July 19th, 2021
** Newsroom July 1, 2021