Claire Dawson
The No Surprises Act (NSA) was passed by Congress in 2020 to protect patients from surprise medical bills. Surprise medical bills arise when insured patients inadvertently receive care from out-of-network hospitals, doctors, or other providers they did not choose. The No Surprises Act establishes new federal protections against balanced billing, more commonly known as surprise billing, for commercially insured patients who receive emergency care or are treated by an out-of-network provider at an in-network facility.
| Characteristics | Values |
|---|---|
| Full Form | No Surprises Act |
| Year | 2022 |
| Purpose | To establish federal protections against surprise medical bills |
| Surprise Medical Bills | Unexpected bills for services received from an out-of-network health care provider or facility |
| Waiver | Patients can waive NSA protection for non-emergency medical services |
| Consent | Consent must be given at least 72 hours in advance or on the day of the appointment if scheduled less than 72 hours in advance |
| Same-day Services | Consent can be given at least 3 hours in advance |
| Languages | The waiver form must be provided in the 15 most common languages in the geographic region |
| Dispute | The act outlines a process for the insurance company and the provider to settle disputes over the provider's charges |
| Good Faith Estimate | Uninsured or self-pay consumers who receive a final bill that exceeds the good faith estimate by $400 or more can dispute the final charges |
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What You'll Learn
The No Surprises Act (NSA)
Under the NSA, health plans that offer emergency coverage must provide it regardless of whether a facility is in-network or out-of-network. Healthcare providers cannot bill patients for out-of-network medical care in emergency situations. The act also covers non-emergency services provided by out-of-network providers at in-network facilities. In these cases, patients must be informed about their protections from unexpected medical bills and given the option to waive these protections and pay more for out-of-network care. This waiver must be given voluntarily and cannot be coerced, and providers can refuse care if consent is denied.
The NSA also addresses situations where patients receive a final bill that exceeds the good faith estimate by $400 or more. In these cases, patients can dispute the final charges. Additionally, the act outlines a process for insurance companies and providers to settle disputes over charges, ensuring a fair resolution.
The NSA has had implications for healthcare providers, with some facing challenges in implementing the new requirements. However, the act is beneficial for consumers, reducing the frequency of surprise billing and making it easier for healthcare organizations to provide care. Overall, the NSA provides important protections for patients seeking medical care and helps to ensure fair and transparent billing practices.
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Surprise medical bills
A surprise medical bill is an unexpected bill from an out-of-network provider or facility. Before the No Surprises Act, if you had health insurance and received care from an out-of-network provider or facility, your health plan may not have covered the entire out-of-network cost. This could have left you with higher costs than if you had received care from an in-network provider or facility. This is known as "balance billing".
Before July 1, 2017, consumers sometimes received unexpected bills from out-of-network providers when they sought services at an in-network facility. This could be due to a billing disagreement between insurers and out-of-network providers. For example, a consumer may have had surgery at an in-network hospital, but the anesthesiologist who provided care was not in their health insurer's network. The consumer did not choose the anesthesiologist, yet they received a bill from the provider after the surgery.
The No Surprises Act, which came into effect on January 1, 2022, protects people covered under group and individual health plans from receiving surprise medical bills when they receive most emergency services, non-emergency services from out-of-network providers at in-network facilities, and services from out-of-network air ambulance service providers. It also establishes an independent dispute resolution process for payment disputes between plans and providers.
If you are uninsured or self-pay for insurance, you should receive a good faith estimate of the costs for your care from your provider when you schedule that care or if you call and request the estimate. After you get the care, if you are billed for an amount more than $400 over the good faith estimate and you received the bill within the last 120 calendar days, you can use the new dispute resolution process to determine the final payment amount.
Some health insurance coverage programs already have protections against surprise medical bills. If you have coverage through Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care, or TRICARE, you are already protected against surprise medical bills from providers and facilities that participate in these programs.
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Consent and waiver
The No Surprises Act (NSA) was passed by Congress in 2020 as part of the year-end omnibus spending bill and took effect in 2022. The act establishes federal protections against surprise medical bills for insured patients who receive care from out-of-network hospitals, doctors, or providers they did not choose.
The NSA includes regulations regarding consent and waiver. For example, the NSA bans surprise billing for emergency services, requiring patients to be treated on an in-network basis without prior authorization. In the case of out-of-network ancillary care at an in-network facility, patients must be treated as in-network unless the law's notice and consent requirements are met. Healthcare providers must use clear and understandable language to obtain patient approval before providing and billing for out-of-network care.
Patients can waive their rights under the NSA and consent to be billed at higher out-of-network rates, but this must be done voluntarily and without coercion. Providers are not allowed to ask patients to waive their rights for emergency services or certain other non-emergency services. Consent must be given at least 72 hours in advance, or on the day of the appointment if scheduled less than 72 hours in advance. For same-day scheduled services, consent can be given as little as 3 hours in advance.
The NSA also requires healthcare providers to provide a one-page disclosure describing the act in plain language to patients. Healthcare facilities must consider how to securely store these waivers to keep patient information safe.
In the context of research, there are additional considerations for consent and waiver. Federal regulations allow for the waiver of informed consent in specific circumstances, such as emergency settings where there is more than minimal risk to participants and a prospect of direct benefit. In some cases, consent may be waived because it is not practicable to obtain consent from a large number of patients, or because subjects are temporarily incapacitated. In these cases, additional pertinent information can be provided to patients after participation.
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Dispute resolution
The No Surprises Act (NSA) is a federal law that came into effect on January 1, 2022, to protect patients from surprise or unexpected medical bills. These surprise bills arise when insured patients inadvertently receive care from out-of-network hospitals, doctors, or other providers they did not choose.
The Act outlines a process for resolving disputes arising from provider charges. This process ensures a fair resolution between the insurance company and the provider. If you are insured and your health plan denies all or part of a claim for service, you can appeal that decision. Your plan documents will contain information on the review process and how to request a review of your plan's decision.
Starting in 2022, patients are generally not responsible for balance bills or out-of-network cost-sharing when receiving emergency care, non-emergency care from out-of-network providers at certain in-network facilities, or air ambulance services from out-of-network providers. In such cases, instead of paying unexpected out-of-network costs, patients only need to pay their normal in-network costs, such as coinsurance, copayments, and amounts paid towards deductibles. The health care provider and the patient's health plan are then responsible for negotiating the total payment amount through an independent dispute resolution process.
Uninsured or self-pay consumers who receive a final bill that exceeds the good faith estimate by $400 or more can dispute the final charges. Additionally, if a patient's health plan offers emergency coverage, it must be provided without prior authorization and regardless of whether the facility is in-network or out-of-network. Healthcare facilities cannot bill patients for out-of-network medical care.
While the NSA provides protections for patients, it is important to note that patients can waive these protections if they choose to do so. This waiver applies only to non-emergency medical services. Out-of-network providers can refuse to provide services to patients who do not waive NSA protection, but only if there are in-network providers available to provide the service, and no other law prohibits that refusal.
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NSA rollout
The No Surprises Act (NSA) was passed by Congress in 2020 and took effect on January 1, 2022. The act establishes new federal protections against surprise medical bills, which commonly arise when insured patients inadvertently receive care from out-of-network hospitals, doctors, or providers they did not choose.
Surprise billing occurs when patients are treated for an emergency at an out-of-network facility or by an out-of-network provider at an in-network facility for non-emergencies without being made aware that the provider is out-of-network. The patient is then unexpectedly billed directly for the balance not covered by their health plan. Under the NSA, surprise billing for emergency services is banned, and patients must be treated on an in-network basis without prior authorization.
The rollout of the NSA has been challenging for healthcare providers, particularly those specializing in emergent care services. Hospital and physician group operators may not be fully aware of all the NSA's requirements, which could lead to rapidly declining revenue and unintentional violations. To address this, several resources have been created by governmental and professional organizations, such as the American Medical Association toolkit.
The NSA also requires out-of-network providers to participate in in-network cost-sharing under a patient's commercial health insurance plan for specific services. These include emergency services, non-emergency services provided by an out-of-network provider at in-network hospitals, and air ambulance transportation services. The act does not apply to traditional private physician practices.
Additionally, the NSA provides patients with the right to dispute final charges if they receive a bill that exceeds the good faith estimate by $400 or more. Patients may also waive NSA protection for non-emergency medical services if they desire, but out-of-network providers can refuse to provide services if patients decline to waive these protections.
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Frequently asked questions
The No Surprises Act (NSA) is a law that establishes federal protections against surprise medical bills. Surprise medical bills arise when insured patients receive care from out-of-network hospitals, doctors, or other providers they did not choose.
Surprise medical bills are unexpected bills for services received from a healthcare provider or facility that the patient did not know was out-of-network until they were billed.
The NSA bans surprise billing for emergency services. Patients must be treated on an in-network basis without prior authorization. It also requires healthcare providers to use clear, understandable language to obtain patient approval before providing and billing for out-of-network care.
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