The No Surprises Act was signed into law as part of the Consolidated Appropriations Act of 2021. It includes several provisions aimed to increase price transparency and patient protections against surprise medical billing (or balance billing). It also includes several reimbursement and policy changes for hospitals, physicians, and insurance carriers.
The provisions of the No Surprises Act target out-of-network-providers. However, the changes will indirectly impact participating providers by changing reporting and communication requirements. It may also impact any arrangements you have with non-participating providers on bundled services.
Starting January 1, 2022, under the rules of the No Surprise Billing provisions, out-of-network providers can no longer balance bill patients for:
- emergency services
- post-emergency stabilization services;
- out-of-network air ambulance services;
- non-emergency ancillary services provided by an out-of-network provider at an in-network facility;
- out-of-network charges without advance notice and consent.
Additional components of the rule include good faith estimates for uninsured patients, the independent dispute resolution (IDR) process, and expanded rights to external review.
Read on for more information about the No Surprises Act.
No surprise medical billing rules as of January 1, 2022:
- Emergency services. Providers cannot balance bill for emergency services. Cost-sharing for emergency services must be determined on an in-network basis without requirements for prior authorization. Any cost-sharing obligation must be based on in-network provider rates.
- Post-emergency stabilization services – The No Surprises Act expanded the definition of “Emergency services" to include post-emergency stabilization services provided in a hospital following an emergency visit. Post-stabilization care is considered emergency care until a physician determines the patient can travel safely to another in-network facility using non-medical transport, that such a facility is available and will accept the transfer, and that the transfer will not cause the patient other unreasonable burdens.
- Out-of-network air ambulance bills. Out-of-network air ambulance providers (defined as medical transport using helicopter or airplane) cannot balance bill patients for more than the in-network cost-sharing amount. Patients will pay only the in-network cost-sharing amount for out-of-network air ambulances. The cost sharing can count toward their deductible. Ground ambulance services are not impacted by the No Surprises Act.
- Services performed by out-of-network providers at an in-network facility. Out-of-network providers (including facilities, physicians, and non-physician practitioners), at an in-network facility, cannot balance bill for covered emergency services or certain covered non-emergency, scheduled services provided at in-network facilities without notice and consent.
- Advance notice and consent. Out-of-network providers and facilities must satisfy notice and consent criteria for billing certain services. These providers must promptly notify the plan or issuer as to whether balance billing and in-network cost sharing protections apply to the item or service and provide a signed copy of any signed written notice and consent documents. Advance notice must be provided:
- Electronically or in paper form (as selected by the patient).
- 72 hours in advance of a procedure
- Three hours in advance for any same day service.
Below is a non-exhaustive list of patient access requirements:
- a good faith estimate of the charges;
- notification that the provider is out-of-network.
- notification that consent is optional, and the patient can instead opt for an in-network provider
- a list of in-network providers at the facility (if the facility is in-network) to refer the patient.
- information on any prior authorization or other care management requirements.
Notice and consent does not apply to the following:
- emergency medicine
- diagnostic services (including anesthesiology, radiology, pathology and laboratory services)
- unforeseen urgent medical needs arising when non-emergent care is provided
- items and services provided by assistant surgeons, hospitalists, and intensivists
- items and services provided by an OON provider if there is not another in-network provider
Disclosure of balance billing protections to your patients
Beginning January 1, 2022, all health care providers must make information on patients' rights publicly available on their websites with respect to balance billing. In addition, a one-page document must be provided; with the specific timeframes: no later than the date and time on which the provider or facility requests payment from the individual (including requests for copayment made at the time of a visit to the provider or facility). In cases where the facility or provider does not request payment from the individual, the notice must be provided no later than the date on which the provider or facility submits a claim for payment to the plan or issuer.
The notice must have information on the requirements under this law, information on any state-level protections and contact information for state and federal agencies to report any potential violations. Lastly, providers should provide patients with a disclosure before sending insurance claims.
Good faith estimates for uninsured, or self-pay individuals
When scheduling a service, or upon request, providers and facilities must inquire about the individual's health insurance status. If the patient is uninsured or opt to self-pay you must supply a good faith estimate of the services to the patient. If the patient is enrolled in a health plan, the provider must send the estimate to the patients' plan.
The good faith estimate must include the charges for the primary treatment, along with any additional items or services, including items or services that may be provided by other providers and facilities.
Independent dispute resolution process (IDR)
The goal of the IDR process is to help keep health care costs down. Out-of-network providers should negotiate and resolve disputes with insurers without adding time or cost to the process. If an out-of-network provider is unsatisfied with the payment received for services rendered, they can first start a negotiation with the plan. The out-of-network provider can initiate IDR to help reach an agreement. The IDR process timeline is as follows:
|Initiate 30-business-day open negotiation period ||30 business days, starting on the day of initial payment or notice of denial of payment |
|Initiate independent dispute resolution process following failed open negotiation ||4 business days, starting the business day after the open negotiation period ends |
|Mutual agreement on certified independent dispute resolution entity selection ||3 business days after the independent dispute resolution initiation date |
|If parties cannot agree to an independent dispute resolution entity, the Departments will select one||6 business days after the independent dispute resolution initiation date |
|Submit payment offers and additional information to certified independent dispute resolution entity ||10 business days after the date of certified independent dispute resolution entity selection |
|Payment determination made ||30 business days after the date of certified independent dispute resolution entity selection |
|Payment submitted to the applicable party ||30 business days after the payment determination |
For more information on the Consolidated Appropriations Act of 2021 or the No Surprises Act, visit the Pennsylvania Insurance Department website.
Information about other components of the Consolidated Appropriations Act of 2021 will be posted on the Provider News Center.
This article is provided for informational purposes only.