Billing Challenges Under No Surprises Act

Tucked into the Consolidated Appropriations Act of 2021, a massive spending bill passed in December 2020, was the “No Surprises Act.” This legislation resolves bi-partisan concern for patients who receive surprise billing for out-of-network medical services.

Effective January 1, 2022, it will be illegal for providers to bill patients above their in-network cost-sharing levels, with some exceptions. This formalizes at a national level the efforts that have been enacted in individual states to eliminate surprise medical bills and protect millions of people with self-funded coverage.

The American Hospital Association has stated that the health system field “strongly supports protecting patients from surprise medical bills,” and encourages members to review the plan closely. Medical providers, hospitals, nursing homes, and others in the field have until the end of 2021 to analyze how this legislation will affect the way they bill patients for services provided. Key takeaways from the “No Surprises Act” include:

• Emergency Services: Most surprise medical bills come as the result of an emergency room visit. Although it may be an in-network facility, services here are often performed by out-of-network providers. Because the event is usually of an emergency nature, there is little time to inform the patient, receive authorization, or explore alternatives. To address this discrepancy, the legislation states that the non-participating providers can no longer bill at out-of-network rates and must work within amounts set forth by state and upcoming Department of Health and Human Services regulations. Insurers must also now cover emergency services without needing prior authorization. Providers and insurers will have the opportunity to negotiate reimbursement amounts, with an independent dispute resolution process.
• Non-Emergency Services: Although not as wide-spread as emergency room services, non-participating medical providers at other facilities must also now bill at a similar amount to the in-network fees. The patient may, however, agree in writing to accept services from a non-participating professional, along with associated fees.
• Air Ambulance Services: Another source of what extremely high surprise bills can be non-participating air ambulance providers. These providers must now bill at the covered rate if the patient’s policy provides for such care.

Both providers and health insurance plans must now assist patients in accessing health care cost information, grant access to a price comparison tool, include additional information on member identification cards, and provide advance notice regarding participation in applicable health plans.

These changes may require providers to review organizational policies, update compliance program testing, and analyze their operations to determine the financial impact of these changes. Our team is here to assist clients in analyzing the impact of these changes and preparing for the new billing protocols in 2022.