The federal “No Surprises Act” took effect on January 1st, 2022, which enforces a new set of balance billing requirements for providers as well as private insurance companies and health plans. Though there are several facets of this act that need to be understood. In some states like Washington, additional regulations might also apply. Though this starts with first asking and answering some important questions.

What Is Considered A Surprise Medical Bill?

Before the No Surprises Act was passed, a patient with health insurance who received care from an out-of-network provider, or an out-of-network facility may not have been covered the entire out-of-network cost. Though there were no active regulations in place that required providers to inform them of a deficit in coverage.

What Is Balance Billing?

In a scenario where there is a gap in coverage or the patient was unaware of being considered out of network, it could leave the patient with higher costs than if they received care from an in-network provider at a facility that offered complete coverage. In addition to any out-of-network cost-sharing you might have owed, an out-of-network provider could also bill the patient for the difference between the billed charge and the specific amount the health insurance plan paid. The only exception to this was if that practice was specifically banned by state law or other provisions, which could apply in states like Washington.

This practice is known as “Balance Billing.” It often left patients with a significant and unexpected bill from an out-of-network provider is also called a surprise medical bill. Though patients with coverage provided through Medicare or Medicaid already enjoy these protections. Which meant that they were never at risk for surprise billing, which also helped guide the language and fine details of the provisions included in the Federal No Surprises Act.

What Are The New Protections For Patients With Health Insurance?

For a patient who receives health coverage through their employer, a Health Insurance Marketplace, or as part of an individual health insurance plan purchased directly from a private insurance company the protections include:

  • A ban on surprise bills the majority of emergency services, this includes out-of-network emergency services and without prior authorization approval.
  • A ban on out-of-network cost-sharing. This includes out-of-network coinsurance as well as out-of-network copayments for the majority of emergency services.
  • A ban on out-of-network cost-sharing on a wide variety of non-emergency services. This limits the amount charged to be no more than what the in-network cost-sharing would be for the same services.
  • A ban on out-of-network charges for certain additional services, such as anesthesiology and radiology that are furnished by out-of-network providers as part of a patient’s visit to an in-network facility.
  • A ban on balance billing for out-of-network charges for specialty services such as anesthesiology and radiology.

The provisions in the Federal No Surprises Act specifically require all health care providers, clinics, hospitals, and other medical facilities to provide patients an easy-to-understand notice that explains the applicable billing protections they are provided.

This information needs to also include who to contact if the patient has concerns that the provider or facility has violated the protections in some way. It also requires that all patient consent is required to waive any billing protections for out-of-network services.

Specific Protections Under The Federal No Surprises Act

The Federal No Surprises Act specifically notes protections for certain services with detailed language that can affect medical billing practices. This includes:

Emergency Care

When it comes to providing emergency care, providers include hospitals, clinics, and other medical institutions that might provide care for an emergency condition. Under the new, No Surprises Act these providers are prohibited from balance billing patients for any out-of-network emergency services. This applies to a variety of medical services such as:

  • Stabilization
  • Post-stabilization
  • Patient transfers
  • Ancillary services
  • Supervised outpatient observation
  • Inpatient observations
  • Outpatient stays that are directed related to rendered emergency services

Required Informed Consent

The new Federal rules enacted by the No Surprises Act allow a non-contracted medical provider to Balance Bill only after the patient is stabilized. This is often defined as a patient who is capable of safely traveling via a non-medical transportation service or one who does not require non-emergency medical transportation.

In these cases, the provider needs to give notice that the additional items and rendered services are non-contracted, and they need to include detailed information about the cost. The provider also needs to verify that the patient has received acknowledgment of the notice and that they are fully capable of consent.

It’s also important to note that this particular Informed Consent provision does not apply for fully insured health plans and those self-funded plans in Washington state. This also applies to individuals that opted into the state balance billing protections. This exception is due to the fact that the federal law does not specifically preempt state balance billing laws, except in instances where the federal protections are broader or the prevailing provisions are considered to be more favorable to patients and consumers.

Ancillary Services

When it comes to ancillary services, the Federal No Surprises Act never allows bill balancing for emergency or non-emergency services. Though there are exceptions for certain non-ancillary services that are provided at an in-network facility. The provider must inform the patient in advance of providing the service that they are non-contracted. Then the provider is required to provide the individual with a reasonable estimate of the charges.

Air Ambulance Transportation

Under the Federal, No Surprises Act, air ambulance services and air ambulance providers are prohibited from balance billing if they are non-contracted. It also specifically requires health plans to cover non-contracted air ambulance services for any services that would otherwise be covered if the air ambulance provider was considered to be in-network. In these cases, they would apply in-network cost-sharing in the same way that other emergency transport services do.

It’s also worth noting air ambulance providers are also included in the Independent Dispute Resolution process, where applicable.