Part One of our “No Surprises Act” blog series
Navigating through the twists and turns of U.S. healthcare insurance is not easy – but with the enactment of the No Surprises Act, patients have protection from surprise medical bills.
The $1.4 trillion Consolidated Appropriations Act of 2021 was signed into law on Dec. 27, 2020, with a provision entitled the No Surprises Act (NSA) included under title I of the law.
The NSA went into effect on Jan. 1, 2022, giving consumers much-needed billing protection when receiving care from emergency departments, out-of-network providers and in-network facilities, and air ambulance services from out-of-network providers.
The ins and outs of insurance networks
Imagine having a medical emergency and needing to choose between going to a nearby hospital that is out-of-network, or an in-network hospital that would take precious, life-saving time to get to – all in order to avoid devastating medical bills after.
This was all too common for insured patients before the NSA. Most insurance plans do not cover the entire cost of care received from a facility or provider not in their network – leaving it up to the patient to research where they could go for care without paying those higher costs.
In cases where a patient receives care from an out-of-network provider, the balance would be owed by the patient to the provider directly – the unexpected balance bill is known as a surprise bill.
A not-so-nice surprise. Examples of scenarios resulting in surprise bills include:
- An accident victim is taken to an out-of-network emergency department.
- A patient has surgery at an in-network facility, but the anesthesiologist is out-of-network.
- An in-network provider has lab work done at an out-of-network lab.
No Surprises Act criteria
The NSA provides new rules aimed to protect consumers, restricts excessive out-of-pocket costs, and requires emergency services to continue to be covered without any prior authorization – regardless of whether or not a provider or facility is in-network.
These protections must meet the following criteria:
- Service is covered under private or commercial health plans that began on Jan. 1, 2022, or after.
- Services were rendered on or after Jan. 1, 2022
It’s important to note that the law does not apply to limited-duration plans, stand-alone plans or Medicare, Medicaid or TRICARE.
Some requirements also apply to providers when caring for uninsured (or self-pay) individuals, like requirements that providers and facilities provide good faith estimates for scheduled care, or upon request.
Continuity of Care
Providers and facilities can change status from being in-network to out-of-network. Before the NSA, it could come as quite a shock for patients when they suddenly receive hefty bills for recent care from what were once in-network services for them.
Consider a cancer patient who needs to be continuously followed by an oncologist. If that doctor becomes an out-of-network provider, the patient is forced to make a distressing decision: stay with the doctor and pay the price or find a new doctor right away.
The NSA protects Continuity of Care by allowing individuals 90 days to find a new, in-network provider to transition to. It also puts the responsibility on the health insurance plans to notify patients when a provider is no longer in-network.
Our “No Surprises Act” blog series will continue with more discussion about NSA violations and provider-specific information.
We’re happy to help navigate the ins and outs of the NSA. If your healthcare organization faces issues with fraud, waste, and abuse, schedule a consultation with us today.