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What Physicians Should Know About the No Surprises Act

By Anna Mueller, MS16 Mar 2022

Homelessness and health are linked, according to a contributor article that explains why homelessness is not simply a housing issue, but a health issue. Many people end up on the streets after losing their jobs due to illness. But it doesn’t stop there. Because their insurance was tied to their job, they also lost their medical coverage.

This is an extreme example of how illness and the ensuing medical bills can negatively impact a patient’s life and wellbeing. Even if a patient has adequate health insurance, they may still anxiously await their bill to see if their insurance is going to cover all or part of their most recent – and expensive – medical procedure. 

Although we have a long way to go when it comes to healthcare reform, the No Surprises Act is a small step in the right direction. Designed to protect patients from these surprise bills, it went into effect on January 1, 2022.

The act prohibits providers from charging patients more than the cost-sharing amount for in-network services. It also applies to any situation where a patient may be surprised by out-of-network billing. 

In a Nutshell: 2 Components of a Surprise Medical Bill

Health insurance is so costly and confusing that almost 30% of adults in one national study delayed getting medical help or went without it altogether as a result. Surprise bills are part of the problem and typically have two components:

Component one: The difference between the designated cost sharing of the patient’s health plan for services provided by out-of-network providers and the cost sharing for services provided by in-network providers. 

Component two: The difference between the full amount the provider charges and the allowed charges that are negotiated by insurance providers. 

What the No Surprises Act Means for Providers

The No Surprises Act protects patients who carry commercial insurance. Patients with Medicare Advantage or other public insurance programs are excluded because they already protect against surprise billing. 

Out-of-network providers must charge patients the in-network provider fee, but can use arbitration to dispute the in-network cost sharing amount of the patient’s health plan. 

According to the American Medical Association (AMA), here are some other considerations:

Disclosure 

“The notice must be provided individually to commercially insured patients, including those in the Federal Employees Health Benefits Program (FEHBP), no later than the time a bill is sent to the patient or a claim for payment is submitted to a health plan.” - AMA Toolkit for Physicians

Generally, providers need to post these policies on their websites, but they do not need to post the policies at their location or provide it to patients if the hospital they are affiliated with already does so.

Update Health Directory Plans

As part of the act, health plans will be required to verify the accuracy of their provider directory every 90 days. As a result, providers are required to provide timely responses to these verification requests. 

Additional Information

The AMA and two physicians filed a lawsuit in mid-December challenging one of the components. The AMA feels this component will “see insurers paying out-of-network providers much less in the coming years.” 

Additionally, Emily Carroll, a senior legislative attorney for the AMA’s Advocacy Resource Center said, “I think we're also going to see significant and dramatic cuts to rates for in-network providers because now they . . . have to negotiate under this median in-network rate ceiling.”

Patients have a limited opt-out from the protections in the act for certain non-emergency services. According to National Law Review, the waiver does not apply to “ancillary services, including emergency medicine, anesthesiology, pathology, radiology, and neonatology; items and services provided by assistant surgeons, hospitalists, and intensivists; diagnostic services; and nonparticipating providers if there is no participating provider option.” 

States are tasked with enforcing the No Surprises Act, and if they fail to do so adequately, the  Center for Medicare and Medicaid Services will take over.

An Opportunity for Better Customer Service

The No Surprises Act is an opportunity to discuss how to make all processes more transparent to patients, whether its how much theyre going to be billed, the scheduling process, or prescribed treatment. Better clarity means better customer service, which will only serve to create happier patients and a stronger bottom line.Subscribe to the Transonic Blog