The 2020 No Surprises Act (NSA) introduced new federal protection against unexpected medical bills and balance billing, the majority of which went into effect on January 1, 2022. The primary No Surprises Act requirements are summarized below and what they imply for you.
- Prevents balance billing for out-of-network emergency care (given in hospital EDs and independent freestanding ERs) and post-stabilization care until the patient consents and can be securely transferred to an in-network facility.
- Prevents balance billing for planned out-of-network services (such as those delivered by a radiologist, pathologist, anesthesiologist, and so on) in an in-network facility when the patient has not been advised or has not performed consent.
- Prevents insurers from charging customer’s greater deductibles (and other cost-sharing) for out-of-network treatment than they pay for in-network care without patient notification and approval.
- Provides equivalent patient protections for air ambulance services but not ground ambulances.
What It Does For Emergency Rooms
- Following out-of-network emergency care, the provider/group bills the patient’s health insurer for the emergency services delivered.
- The f/group can charge only the patient’s expense amount. This price is based on the average in-network cost for comparable plans and services in that geographic area (the Qualified Payment Amount, or QPA).
- The provider/group is not permitted to “balance bill” fees in addition to the patient’s in-network expense.
- The insurance plans must make payments directly to the provider/group, detailing the total amount the policy thinks it owes within 30 days.
- If the provider/group does not agree with this figure, it may challenge it with the insurer within a 30-day “open negotiation” phase.
- Suppose the provider/group is still unable to agree on a reasonable pricing level. In that case, the provider/group may pursue independent dispute resolution (IDR), a form of arbitration/mediation procedure in which an independent outside organization determines the fairest payment.
Disclosure Requirements As A Provider/Emergency Room.
Providers/groups and other professionals qualified under the No Surprises Act must tell all their patients about the new balance-billing protections.
- Prominently at the facility’s site.
- As a summary report sent to the patient in person, via mail, or by email—the fact sheet can be generated using a CMS template. (Template for Disclosure Requirements)
- On the webpage of a facility/emergency room
If you have a formal agreement in place, your hospital/emergency department can take care of the first two needs for emergency care. It is advised that the patient be given the paperwork at the time and site of care. Suppose your hospital declines to assume this obligation. In that case, you must provide the disclosure fact sheet to the patient at or before collecting any cost-sharing payments from them, or at the very least before filing a claim with the patient’s insurer.
Good Faith Estimates
The No Surprises Act requires physicians who offer non-emergency care to provide good faith estimates of services when care is planned at least 72 hours in advance or upon demand from uninsured or self-pay patients.
For emergency care, you are not required to provide a good faith estimate.
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