What the “No Surprises Act” Means for Your Organization

What the “No Surprises Act” Means for Your Organization

The No Surprises Act (Act), a component of the recently enacted Consolidated Appropriations Act, requires health plans and providers to hold patients harmless from surprise medical bills.  The Act, while protecting the patient from devastating surprise out-of-network medical bills, will present significant financial challenges for providers if they don’t address internal processes that include patient access, insurance verification, billing and collections. 

The Act directs that patients are only required to pay the in-network cost sharing amount, including deductibles, for out-of-network emergency care and certain ancillary services provided by out-of-network providers at in-network facilities, and out-of-network care provided at in-network facilities without the patient’s informed consent. Also, out-of-network facilities and providers are prohibited from sending patient balance bills for more than the in-network cost sharing amount.  In addition, the balance billing of patients is prohibited unless that provider provides the patient notice of their network status and an estimate of charges 72 hours prior to receiving the out-of-network services and the patient provides the consent to receive the out-of-network care. For any appointments made within 72 hours of receiving services the patient must receive the notice the day the appointment is made and consent to receive the out-of-network care. Some providers won’t be able to balance bill patients even with consent. This includes anesthesiologists, pathologists, and radiologists. Air ambulance services (but not ground ambulance service) are also addressed in the Act.

Determination of the amount health plans must pay providers for out-of-network claims (Section 103 of the Act) includes a 30-day open negotiation period where providers and health plans can settle the claims. If the parties are unable to reach a negotiated settlement, health plans and providers have the option of entering the Independent Dispute Resolution (IDR) process of which one offer will prevail.

With one year before the Act becomes effective, providers have an opportunity to evaluate how they will need to comply with the new legislation. One thing is certain though. Price transparency, which just became law on January 1, 2021 plays a large part in the new legislation. If your organization is struggling to meet these requirements, we have a cloud based software solution that will meet the Hospital Price Transparency requirements and will position your organization to meet the price transparency requirements of the Act.

Does your organization need assistance in implementing this new legislation? Our experienced group of professionals can help. 

Contact our Reimbursement Team

Sari K. Reikes - Director

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Colin R. Conklin -Senior Consultant

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