Surprise Medical Billing

Caroline Billings
Release Date- January 24, 2022
Review Date- April 4, 2022

The No Surprises Act was signed into law on December 27, 2020, as a portion of the Consolidated Appropriations Act of 2021 (H.R. 133; Division B.B.—Private Health Insurance and Public Health Provisions)- Detailed Summary of No Surprises Act | AHA. This act will confront the issue of surprise medical billing at a national level. In addition, many sections of the Surprise Billing legislation went into effect on January 1, 2022. The Departments of HHS, Labor, and Treasury are assigned to guide regulatory requirements for enacting the legislation (AHA-Detailed Summary of No Surprises Act).

No Surprises Act- Contents

Most health insurers carry provider and healthcare facility networks that agree to accept a certain amount of money for their care. Out-of-network providers generally charge patients much more money than in-network providers/facilities that contract with insurers. To combat this, “balanced billing” was implemented in some states, where out-of-network providers might charge patients the difference between the bill and the amount their insurance would pay. This type of billing is prevalent in air ambulance services, where individuals do not have much control over who gives them care. The No Surprises Act was introduced in Congress as a way to significantly lower the cost of surprise bills for patients, especially since out-of-network surprise bills do not count toward a patient’s deductible.

Among other provisions, the No Surprises Act:

  • prevents patients from acquiring surprise medical bills that result from a lack of total insurance coverage for out-of-network physicians who work for in-network facilities, emergency services, and air ambulance coverage
  • Only requires payment from patients for their in-network cost-sharing amount. From here, care providers and insurance companies negotiate reimbursement.
  • Provides providers and insurance companies an independent dispute-resolution system in case reimbursement solution disputes arise. The No Surprises Act does not set any benchmark amounts for insurers to reimburse providers.
  • necessitates that care providers and health plans help patients access healthcare cost information

Requirements Related to the No Surprises Act

The Departments of Health and Human Services, Labor, and Treasury, and the Office of Personnel Management (OPM) collectively released interim final rules with comment periods (IFC) on July 1 and September 30, 2021, regarding new protections from surprise medical billing and excessive sharing of cost information for patients receiving healthcare. More information regarding determining out-of-network rates and giving patients notice of these IFCs can be found here.

The July 2021 Ruling

The September 2021 Ruling

  • Outlines the “federal dispute resolution process, good faith estimate requirements for the uninsured or those who use self-pay, requirements for patient-provider disputes when the patient is uninsured or uses self-pay, and some external review provisions of the No Surprises Act.
  • The regulations regarding independent dispute resolutions, good faith estimates for uninsured individuals, patient-provider dispute resolutions, and the external review provisions of the No Surprises Act can be found here.

January 2022 Updates

Other Resources