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.
For more information on Surprise Billing please visit https://www.cms.gov/nosurprises.