In 2021, the Consolidated Appropriations Act established several new requirements to protect consumers from unexpected medical bills, known as The No Surprises Act. This Act radically changed the landscape in medical billing practices in several key ways. For example, “balance billing” for emergency services was outlawed, meaning that if one has sought care at the nearest hospital, and it happened to be out-of-network with your insurance company. The insurer must pay the provider at essentially in-network rates. The patient’s responsibility (cost sharing) is limited to in-network levels or less for co-pays, deductibles, and out-of-pocket amounts. The statute applies to consumers enrolled in group plans, individual health plans, and federal employee health benefits plans. This does not apply to Medicaid and Medicare patients. Balance billing for air ambulances was also eliminated by The No Surprises Act.
In most cases, ordinary (non-emergency) events, providers must give a good faith estimate of expected charges to uninsured and self-pay patients at least three days before a scheduled service, or upon request. *This is the primary protection for the uninsured under The No Surprises Act. If the final bill is more than $400.00 over the estimate, the Patient-Provider Dispute Resolution (PPDR) may be invoked.
Providers must also submit directory information to the plan or insurance issuer at a minimum upon the occurrence of certain delineated events. They must reimburse participants, beneficiaries, or enrollees who paid a provider bill more than the in-network cost sharing amount in reliance on an incorrect provider directory. If already paid, reimbursement must be for the full amount paid more than the in-network cost sharing, plus interest.
There are several other areas affected by this broad statutory rule. It is important to note that while many people are aware of The No Surprises Act, there are many who may be unfamiliar with its full scope and the various rules that must be followed, as well as the many nuances of its operation on its most focused levels.
For now, the federal government operates 7-days per week. The “No Surprises Helpline” can be reached at 1-800-985-3059. This can be used to obtain information concerning the applicability of the Act to your or your loved one’s situation, as well as possibly assist in pursuing a complaint against a provider or insurer. At times it takes expertise to determine whether a particular bill is within its scope. Don’t Stall—Just Call— Human Health Advocate. We are here to help.