No Surprises Act: Take the Surprise Out of Unexpected Medical Billing

As much as we would like to think the current medical billing and payments system is a straightforward, transparent one–time and time again, consumers have had to find out the hard way that it is actually quite the opposite. Studies have shown that surprise medical bills affect 1 in 5 of all emergency room visits across the United States.

So, what exactly is surprise medical billing? Insured consumers often get unexpected bills when they unknowingly receive treatment from providers that may not be part of the network of their coverage. A prominent example of surprise medical billing is inclusion of payments for out-of-network healthcare providers, such as anesthesiologists, by in-network hospitals for non-emergency procedures.

This leads to disputes between providers and insurance companies, not to mention, unwanted stress on the consumers who have to deal with the hassle going back and forth to resolve the matter. Many of these disputes may not work out in the favor of the consumer at the end of the day, which means having to bear the financial burden out of pocket.

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Understanding the No Surprises Act

In the latter half of 2021, the No Surprises Act was introduced. This Act takes patients under federal protection from unexpected out-of-network bills from providers. According to the Council for Affordable Quality Healthcare (CAQH), The No Surprises Act, signed into law as part of the Consolidated Appropriations Act of 2021 addresses surprise medical billing at the federal level.

Section 111 of the Act requires health plans to provide an Advanced EOB for scheduled services at least three days in advance to give patients transparency into which providers are expected to provide treatment, the expected cost, and the network status of the providers. Additionally, Section 112 states that healthcare providers and facilities must verify, three days in advance of a service and no later than one day after scheduling a service, what type of coverage the patient is enrolled in and provide notification of a Good Faith Estimate of charges to the payer client

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Following are some of the key features of this new act, and how it affects the way medical billing will now be processed.

Key Features of the No Surprises Act

  • Restrictions on surprise billing for all patients belonging to employer-based/individual health plans for emergency or non-emergency care from out-of-network professionals at in-network hospitals. This also includes air ambulance and out-of-network facilities.
  • Restriction on out-of-network cost sharing for emergency and non-emergency services, as well as restrictions on out-of-network charges for supplemental care.
  • Establishment of independent dispute resolution processes to settle out-of-network payments between hospitals and insurance companies.
  • Establishing fair estimates of medical services, treatments, care, and items for patients who are not covered by insurance plans.
  • Establishment of independent patient-provider dispute resolution for uninsured patients.
  • Streamlining processes to appeal certain decision by health plans.
  • Requirement for group health plans to submit specific information regarding prescription drugs.

As of January 1st, consumers in the United States have been granted protection from hidden medical charges that have been a constant source of distress, despair, and misery among patients who require emergency services, as well as those with chronic medical illnesses. If you wish to learn more about the Act, and how you can take action, feel free to reach out – At Payspan, we’re here to simplify healthcare payments for you.

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