Robbins: How the No Surprises Act works |

Robbins: How the No Surprises Act works

There was a recent story in the news. A gentleman in Kentucky told his manager that a birthday party — for him — would cause him enormous stress. He asked his employer to, please, not celebrate his birthday. It would bring back bad childhood memories of his parents’ divorce.

Heedless of his plea, the employer did anyway, which caused him to suffer a panic attack. The next day, his supervisor upbraided him for “stealing his coworkers’” joy and “being a little girl,” which caused him to suffer a second panic attack. After the second attack, the gentleman was fired. Then he got a lawyer and brought suit.

The suit alleged that the company discriminated against him based on a disability and that the company retaliated against him for demanding a reasonable accommodation to his condition. After a two day trial, he won. The jury awarded him $150,000 for lost wages and an additional $300,000 for emotional distress.

OK. Apparently, not everyone likes a surprise. But I’d venture to say that most of us do— at least most of time. Except, perhaps, when it comes to things like our health or our pocketbook or, worse, when the two of them butt heads.

Thus, the No Surprises Act which, as you might glean from its name, is supposed to spare us surprises in the medical billing arena.

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The Consolidated Appropriations Act of 2021 was enacted on Dec. 27, 2020, and contains many provisions to help protect consumers from surprise bills, including the No Surprises Act under Title I and Transparency under Title II.

Effective as of Jan. 1 of this year, consumers now have new billing protections when getting emergency care, non-emergency care from out-of-network providers at in-network facilities, and air ambulance services from out-of-network providers. Through new rules aimed to protect consumers, excessive out-of-pocket costs are restricted, and emergency services must continue to be covered without any prior authorization, and regardless of whether a provider or facility is in-network.

Before the No Surprises Act, if you had health insurance and received care from an out-of-network provider or an out-of-network facility — even unknowingly — your health plan may not have covered the entire out-of-network cost. This could have left you with higher costs than if you had received care from an in-network provider or facility. In addition to any out-of-network cost-sharing you might have owed, the out-of-network provider or facility could bill you for the difference between the billed charge and the amount your health plan paid unless banned under the law of your particular state. This is known as “balance billing.” An unexpected balance bill from an out-of-network provider is also called a ”surprise medical bill” which the Act is meant to ban.

The No Surprises Act protects people covered under group and individual health plans from receiving surprise medical bills when they obtain most emergency medical services, non-emergency services from out-of-network providers at in-network facilities, and services from out-of-network air ambulance service providers. It also establishes an independent dispute resolution process for payment disputes between plans and providers, and provides new dispute resolution opportunities for uninsured and self-pay persons when they receive a medical bill that is substantially greater than the good faith estimate they are entitled to receive from the provider prior to care being rendered.

Starting Jan. 1 of this year, the new protections are intended to prevent surprise medical bills. If you have private health insurance, these new protections ban the most common types of surprise bills. If you are uninsured, or decide not to use your health insurance to pay for services, under these protections you can often get a good faith estimate of the cost of your care up front, before your visit. If you disagree with a bill, you may be able to dispute it.

Under the act, if you get your health insurance from your employer, a health insurance marketplace, or an individual health insurance plan you purchased directly from an insurance company, the new rules will:

  • Ban surprise bills for most emergency services, even if you receive them out-of-network and without prior authorization
  • Prevent you being charged for more than in-network cost-sharing for out-of-network emergency services
  • Bar you from being charged a premium amount for certain additional services (such as radiology or anesthesiology) provided by out-of-network providers as part of your visit to an in-network facility
  • Assure that health care providers must provide you with an easy to understand notice explaining the applicable billing procedures and whom to contact if you have concerns

If you don’t have health insurance or prefer to pay for your own care without employing your insurance, the new rules mandate that you receive a good faith estimate of services before the care is rendered. If you are billed at least $400 more than the good faith estimate, so long as you file your dispute within 120 days of the billing date, you may dispute it.

One last little bit: Folks with Medicare and Medicaid already enjoy these protections and are not at risk for surprise billing. As such, the act does not include them or unsettle their security.

The No Surprises Act is meant to … well … eliminate surprises. And wouldn’t that give each one of us a little less reason for panic in our sometimes over-complicated lives?

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