The No Surprises Act likely a big win for patients and consumers

Wednesday, June 23, 2021

The No Surprises Act protects patients against surprise medical bills arising out of certain out-of-network emergency care and provides payment and billing dispute resolution between medical providers and health insurers.

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Starting Jan. 1, 2022, it will be illegal for healthcare providers to bill patients for more than the in-network price of a service in almost all scenarios where surprise out-of-network bills occur, except for ground ambulance transport (which can cost patients an average of $450 after insurance kicks in). Under the federal legislation, health insurance plans must treat these out-of-network services as if they were in-network when calculating the patient’s part of the cost. The No Surprises Act also creates a new arbitration process to determine how much insurers must pay out-of-network providers and gives out-of-network providers the opportunity to protest payment through the process.

Surprise billing largely occurs during medical emergencies, when patients, through no fault of their own, receive care at an out-of-network facility or are treated by out-of-network physicians at an in-network hospital. It also happens during elective care procedures: Patients choose an in-network facility and principal physician, but typically aren’t able to choose their anesthesiologist or other ancillary providers that may contract with health insurers separately from the in-network facility where they practice.

Highlights from the No Surprises Act:

• Protections will apply to all commercially insured enrollees (public insurance programs Medicare and Medicaid already include protections from surprise bills).
• Protects patients from receiving surprise medical bills resulting from gaps in their health insurance coverage for emergency services and certain services provided by out-of-network clinicians at in-network facilities, including air ambulances (but excluding ground ambulances).
• Patients are only responsible for paying their in-network cost-sharing amount.
• Allows healthcare providers and insurers to access an independent dispute resolution process in the event that disputes arise around reimbursement.

For more information on the No Surprises Act, please visit the American Journal of Managed Care’s website.