March 16, 2023 | 2 min read
A new law prohibits surprise medical billing and attempts to make health care prices more transparent.
WHAT: In 2020, Congress passed the No Surprises Act (NSA), a new law that protects patients from surprise medical bills and requires health plans and providers to make prices more transparent to the general public.
IN BRIEF: Insured patients may not be asked to pay more than they do for their health plan’s in-network providers for emergency services and many non-emergency services. Even if the clinicians that provided treatment do not contract with an insured’s health plan, they may not send a medical bill to a patient for any amount beyond the patient’s expected out-of-pocket expenses. Multiple new processes are required of plans and providers to allow patients to know how much services will cost before treatment is provided.
WHEN: Effective January 1, 2022.
Balance Billing: Patients only pay their in-network cost-sharing rate when they receive emergency care, or when they are unknowingly treated by an out-of-network provider at an in-network facility. Patients may waive their balance billing protections, with some exceptions.
Transparency Provisions: Within 1-3 days before patients receive a service –
- Providers must provide an itemized good faith estimate (GFE) of expected charges to uninsured and self-paying patients.
- Plans must provide an advanced explanation of benefits (AEOB) that includes a provider’s GFE, expected patient expenses, and whether coverage is subject to a review of medical necessity.
The NSA also establishes two processes for payment dispute resolution:
- Patient-Provider Dispute Resolution (PPDR): Uninsured and self-paying patients can request an independent review of their responsibility to pay if their bill is $400 more than the GFE.
- Independent Dispute Resolution (IDR): Plans and out-of-network providers must submit their final reimbursement offers to a federal arbitration process when they are unable to agree upon a reimbursement rate.
Maverick’s Perspective 💡
The No Surprises Act represents a bipartisan backlash against a long-standing practice by hospitals and physicians to surprise insured patients with high medical bills when they unknowingly accepted treatment from providers that were not in their plan’s network. To help make patients more informed consumers, the NSA layers price transparency requirements on top of the existing hospital and payer price transparency rules. It is important that plans and providers review and coordinate all of these requirements and monitor the changing landscape as these new rules evolve.
Last Updated on November 28, 2023
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