Patient Protections Against Surprise Billing

The No Surprises 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 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.

  • Insurance companies must cover emergency services without any prior authorization and regardless of provider’s network status (in or out of network).  Also, the insurance company must pay at in-network rates. After being stabilized, the insurance company may require that the patient be transferred to an in-network facility.
  • Cost Sharing Determination – Health plans must follow a prescribed process for determining patient cost-sharing. 
  • Non-emergency services performed by out of-network providers at in-network facility – the patient is protected against surprise medical bills when seen by an out-of-network provider in an in-network facility in certain circumstances. 
  • There is an Independent Dispute Resolution (IRD) process to help resolve disputes between the health plan and the provider.  There is a 30 day open negotiation period. If an agreement isn’t reach at the end of 30 days, the provider and health plan have 3 days to agree on IDR entity to resolve the case. There is a fee for this service that will be paid by the party with the losing bid.
  • Providers cannot balance bill patients for covered emergency services or certain covered non-emergency services beyond their normal in-network cost share. Balance billing at out-of-network can only occur in certain circumstances.
  • Providers failing to follow guidelines may face a $10,000 penalty per violation.  It will be critical to identify any claims not paid in-network and ensure that criteria is met to balance bill the patient before sending statements.
  • Insurance companies are being required to issue ID cards with in-network and out-of-network copayments. 

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