The No Surprises Act: Protecting Patients and Promoting Transparency

The No Surprises Act is a significant piece of federal legislation that aims to address the issue of surprise medical bills and enhance transparency in healthcare costs. Enacted as part of the coronavirus relief package in 2020, this act has far-reaching implications for patients, providers, and insurers. Let’s delve into the key aspects of the No Surprises Act and understand its impact. All healthcare practices should be aware of these laws as they most certainly affect practices. They have a particularly strong impact on practices with a large self-pay or OON clientele.

What Is the No Surprises Act?

The No Surprises Act provides patients with protection from unexpected medical bills under specific circumstances. Here are the main points:

1. Surprise Medical Bills: The act prohibits insurers from passing along bills from doctors and hospitals that are not covered under a patient’s plan. These surprise bills have often left patients responsible for substantial outstanding fees.
2. Transparency: The legislation mandates transparency regarding healthcare costs. Patients should have access to clear information about the cost of medical services, allowing them to make informed decisions.
3. In-Network Cost-Sharing: Patients are held liable for in-network cost-sharing amounts only. This means that if you receive care from an out-of-network provider at an in-network facility, your financial responsibility should align with in-network rates.

Key Provisions of the No Surprises Act

1. Protection Against Surprise Bills

The No Surprises Act addresses surprise billing situations in the following scenarios:

– Emergency Services: Patients are protected from surprise bills when they receive emergency services from out-of-network providers. For instance, if you visit an out-of-network emergency room during a medical crisis, you won’t face unexpected charges.

– Non-Emergency Services at In-Network Facilities: If you receive non-emergency services from an out-of-network provider at an in-network facility (such as during a scheduled surgery), the act ensures that you won’t be hit with surprise bills.

– Air Ambulance Services: The act also covers air ambulance services, preventing patients from being caught off guard by exorbitant charges.

2. Independent Dispute Resolution (IDR) Process

The No Surprises Act establishes an IDR process to resolve disputes between providers and insurers regarding out-of-network payments. Here’s how it works:

– Certified IDR Entities: Independent dispute resolution entities (IDR entities) are certified to handle payment disputes. Providers and insurers can engage in this process to reach a fair resolution.

– Patient Rights: Patients have the right to a transparent and fair process. IDR ensures that disputes are resolved without burdening patients with unexpected costs.

3. Patient Rights and Responsibilities

Patients have certain rights and responsibilities under the No Surprises Act:

– Know Your Patients Rights: Familiarize yourself with the protections offered by the act. Understand when your patients are shielded from surprise bills and how to navigate the IDR process if needed.

– Stay Informed/Clearly Inform Patients: Be clear about healthcare costs, including in-network and out-of-network rates. Communicate clearly with patients about their choices about your care.

Conclusion

The No Surprises Act represents a significant step toward protecting patients from financial shocks due to surprise medical bills. By promoting transparency and fairness, it aims to create a more equitable healthcare system. As providers it is important to stay informed and provide clear information to patients under this crucial legislation. Making mistakes or ignoring this legislation could be very costly to a practice.

For more details and official resources, visit the [CMS No Surprises Act page](^1^).

*Disclaimer: This blog post provides general information and should not be considered legal advice. Consult with a qualified professional for personalized guidance.*

Source: Conversation with Bing, 3/20/2024
(1) No Surprises Act | CMS. https://www.cms.gov/nosurprises.
(2) No Surprises Act Definition, Improved Healthcare Transparency. https://www.investopedia.com/no-surprises-act-definition-5204726.
(3) No Surprises: Understand your rights against surprise medical bills. https://www.cms.gov/newsroom/fact-sheets/no-surprises-understand-your-rights-against-surprise-medical-bills.
(4) Surprise medical bills are the target of a new law. Here’s how it works …. https://www.npr.org/sections/health-shots/2021/10/14/1045828215/ban-on-surprise-medical-bills.