In December of 2020, Congress passed the No Surprises Act, which provides protection nationwide for patients from surprise medical bills and prohibits balance billing for certain out-of-network care. The Act’s goal is to protect those individuals who unknowingly receive care from out-of-network doctors, labs, or other providers and safeguard against those surprise medical bills. “No patient should forgo care for fear of surprise billing,” said Health and Human Services Secretary Xavier Becerra in a statement. “Health insurance should offer patients peace of mind that they won’t be saddled with unexpected costs.”
While it is beneficial to patients, the No Surprises Act is causing concerns for healthcare insurers and providers, including complicating pricing, negotiation, settlement, and arbitration processes. With just under five months until the Act comes into effect on January 1, 2022, the pressure is on both payers and providers to adapt their systems, technology, and processes to be in compliance.
In a conversation between Matthew Albright, Chief Legislative Affairs Officer at Zelis, Albright shared that “the multiple requirements mandated in these policies will be a very difficult lift for providers and payers.” To this end and in order to be compliant, payers and providers will have to adapt internally, outsource solutions, or a combination of the two to comply with all the requirements mandated in the policy.
Healthcare organizations will have until the start of the next year to determine the best fit that supports their operation and those who rely on them.
High-level provisions of the legislation:
Prohibits providers from balance billing patients for 1) emergency care from nonparticipating (out-of-network) facilities or providers; 2) non-emergency care from nonparticipating (out-of-network) providers in an in-network facility; and 3) nonparticipating air ambulance care
- OON providers in in-network facilities are exempt if they provide proper notice and obtain patient consent within certain timelines.
- The notice and consent exemption does not apply to OON services in in-network facilities with respect to emergency medicine, anesthesiology, pathology, radiology, neonatology, and diagnostic services.
- Facilities include hospitals, independent freestanding emergency departments, hospital outpatient departments, critical access hospitals, ambulatory surgical centers, and any other facilities to be specified by The U.S. Department of Health and Human Services (HHS).
- Initial payment to provider by payer is not directly tied to a reimbursement benchmark. Payers and out-of-network providers have several opportunities to negotiate and settle on reimbursement in surprise billing situations.
More information and rulings on the legislation are expected to come over the following months. Moreover, the Act is “quite broad and highly impactful for payers, providers, and members. It brings an entirely new and complex set of rules and considerations to the forefront and really requires extensive planning to ensure the infrastructure is in place to support both the payer and provider requirements for 2022,” said Albright.
While the No Surprises Act is causing concerns about billing for both payers and providers is real and legitimate, it will bring many benefits to patients. Over the next few months, healthcare organizations should focus on learning more about the No Surprises Act and its requirements in order to meet the rapidly approaching deadline. While complying with the Act will be a lot of work, it will be well worth it for higher customer and patient satisfaction levels.
To learn more about the No Surprises Act, click here.