No Surprise Act
Today the out-of-network provider can bill consumers for the difference between the charges the provider bills, and the amount paid by the consumer’s health plan. This is known as balance billing. An unexpected balance bill is called a surprise bill. New billing protections will be in effect starting January 1st. This post gives a brief overview on the topic. Please review the hyperlinks and payer guidelines for the most current updates.
What are the new protections for your patients and how does this affect you?
For consumers who get coverage through their employer (including a federal, state, or local government), through the Health Insurance Marketplace® or directly through an individual health plan, beginning January 2022, these rules will:
Ban surprise billing for emergency services. Emergency services, even if they are provided out-of-network, must be covered at an in-network rate without requiring prior authorization.
Ban balance billing and out-of-network cost-sharing (like out-of-network co-insurance or copayments) for emergency and certain non-emergency services. In these situations, the consumer’s cost for the service cannot be higher than if these services were provided by an in-network provider, and any coinsurance or deductible must be based on in-network provider rates.
Ban out-of-network charges and balance billing for ancillary care (like an anesthesiologist or assistant surgeon) by out-of-network providers at an in-network facility.
Ban certain other out-of-network charges and balance billing without advance notice. Health care providers and facilities must provide consumers with a plain-language consumer notice explaining that patient consent is required to get care on an out-of-network basis before that provider can bill the consumer.
Disclose patient protections against balance billing. A provider or facility must disclose to any participant, beneficiary, or enrollee in a group health plan or group or individual health insurance coverage to whom the provider or facility furnishes items and services information regarding federal and state (if applicable) balance billing protections and how to report violations.
Providers or facilities must post this information prominently at the location of the facility, post it on a public website (if applicable) and provide it to the participant, beneficiary or enrollee in a timeframe and manner outlined in regulation.
Providers will have further requirements in this posted overview by CMS
For consumers who don’t have insurance, these rules make sure they’ll know how much their health care will cost before they get it, and might help them if they get a bill that’s larger than expected.
The rules do not apply to people with coverage through programs like Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care, or TRICARE because these programs have other protections against high medical bills.
For more information hyperlinks to information on this topic can be found at:
For Compliance questions, please contact Sandra Setlock at 716-389-3236 or firstname.lastname@example.org