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What you need to know

The No Surprises Act for Providers

The No Surprises Act will have a large impact on healthcare providers and facilities, including administrative process changes and additional requirements to follow.

What the No Surprises Act Means for Providers

For healthcare providers, the No Surprises Act provides a clear process for resolving out-of-network payment disputes. When the provider and the health plan can’t come to an agreement, a neutral third party will determine the payment for a service.

In such an instance, either party can initiate the dispute resolution process. The third party is determined by the provider and the health plan together, or by the Department of Health and Human Services (HHS) if the other two parties can’t agree on an arbitrator.

Independent Dispute Resolution Factors

Once an IDR third party entity has been identified, there are a number of factors the entity must take into consideration in order to arrive at a fair and final decision. They may look at the median payment rate for the service provided, the provider’s expertise in providing a particular service, if there are other providers in the area who can perform the same service, and the provider’s previous efforts to negotiate with the health plan.

Provider and Insurer Responsibilities

The NSA also creates some new responsibilities for health care providers and facilities to inform patients about their rights and protections against surprise billing.

Providers are required to post the following on all websites and to provide this information to all insured patients seeking treatment:

  1. The balance billing prohibitions under the No Surprises Act
  2. Any applicable state requirements with respect to balance billing
  3. Information on contacting any applicable state or federal regulatory agency if the individual believes the provider or facility has violated balance billing restrictions

 

Additionally, providers are required to notify a patient of their out-of-network status and obtain the patient’s written consent to receive out-of-network services more than 72 hours before the service is delivered.

Health plans have new responsibilities as well. The NSA requires insurers to provide:

  1. A verified list of their in-network providers, which must be reviewed and updated every 90 days.
  2. Physical or electronic ID cards that include patients’ deductible, out-of-pocket maximum, and customer assistance contact information.
  3. A price comparison resource on the health plan’s website with data from the current plan year and patients’ local area and providers.

Video: The No Surprises Act Overview

The NSA will have a broad impact, and there are many implications for providers. How can Naviguard help?

FAQs

The No Surprises Act prohibits surprise medical bills for out-of-network care for most emergency situations, including out-of-network air ambulances, and out-of-network care provided at in-network facilities As a result, patients will be protected from surprise bills in most situations where they have little or no control over who provides their care.

However, the law does not apply if the member chooses to receive items and services from an OON provider. The No Surprises Act also does not apply for ground ambulance services, or when the law’s notice and consent requirements are met.

The No Surprises Act also establishes an Independent Dispute Resolution (IDR) process, also referred to as arbitration, to resolve disputes between OON providers and insurers/health plans.

Under the law, effective upon plan years beginning on or after January 1 2022, out-of-network providers are prohibited from surprise medical bills in situations where they have little or no control over who provides their care, like for all emergency services (except ground ambulance), or when an out-of-network provider is involved in their care while they are at an in-network facility.

If a patient receives a service that is covered by the No Surprises Act, the law caps the patient’s cost share to what it would be if the services were provided in-network.

Patients are protected from surprise bills when they receive:

  • Out-of-network emergency services, including air ambulance (but not ground ambulance)Covered medical items and services performed by an OON provider at an INN facility (unless the provider follows the notice and consent process described above).
  • Out-of-network non-emergency, ancillary services* provided at in-network facility.
  • Non-emergency, non-ancillary services provided at in-network facility, and the provider did not get your prior consent in the way the No Surprises act requires.

 

And, for the above services, the health plan must ensure that the patient’s cost-share (in other words, coinsurance, copay, deductible):

  • Is the same as it would have been if the service was provided in-network. Out-of-network non-emergency, ancillary services* provided at in-network facility.
  • Is based on what the plan would pay an in-network provider.
  • Counts toward the patient’s in-network deductible.
  • Counts toward the patient’s out-of-pocket maximum.

 

*Ancillary services include services related to emergency medicine, anesthesiology, pathology, radiology and neonatology; certain diagnostic services (including radiology and laboratory services); items and services provided by other specialty practitioners; and items and services provided by an out-of-network provider if there is no in-network provider that can provide that service.

Remember: In-network providers are not allowed to balance bill. If you are asked to give up your protections against surprise billing through the Notice and Consent form, you have options. Contact your health plan for help finding an in-network option.

You can find an explanation of what out-of-network laws are currently in place in your state here.

The law may not pre-empt state surprise billing laws that establish a process for determining OON reimbursement for covered items and services for insurers subject to the state’s law.

Insurer and health plans: provisions applicable to insurers and health plans are enforced by the applicable federal agency (the Departments of Health and Human Services, Labor, and the Treasury).

Providers and facilities: provisions applicable to health care providers and facilities are enforced by the Department of Health and Human Services which may impose fines of up to $10,000 per violation.

States: provisions applicable to providers and facilities (including air ambulance) may be enforced by the states.

The law is effective for policy and plan years on or after January 1, 2022.  Therefore, if a plan renews during 2022, the No Surprises Act will go into effect on the renewal date (which is 12/1/22 in this example).

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