Understanding Patient Rights Under the No Surprises Act
The No Surprises Act (NSA) went into effect on January 1, 2022 and is expected to provide widespread protections to patients from surprise medical bills, which can otherwise be financially devastating.
What is “Surprise Medical Billing”?
A surprise medical bill is an unexpected bill for services rendered at an out-of-network facility, or by an out-of-network provider at an in-network facility. Such bills typically charge a higher cost than a patient’s in-network rate.
On top of that, the out-of-network facility or provider may engage in the practice of balance billing, in which the patient is billed for the difference between what their health plan pays and what the facility actually charged.
Moreover, surprise medical bills do not typically count towards a patient’s annual out of pocket maximum, making the financial burden of such charges even more severe.
Thankfully, the newly enacted NSA protects individuals with health insurance—whether it be employer-sponsored insurance, individual insurance, or insurance through the Marketplace—by banning these unfair billing practices. Additionally, the NSA affords added protection to uninsured or self-paying individuals by requiring facilities to provide a good faith estimate of the cost of certain medical services.
NSA Changes to Emergency Services Billing
The NSA applies to bills for emergency services—including screening and stabilization care sought by patients who believe they are having an emergency—received at a hospital’s emergency department, freestanding emergency departments, or urgent care centers that are licensed to provide emergency care. Surprise medical bills are especially common in the context of emergency care, since a patient does not have the time or ability to research and select a more affordable in-network facility for treatment. Thus, they may unknowingly receive care at an out-of-network facility.
Under the new NSA, however, plans that provide coverage for emergency treatment must provide such coverage for out-of-network facilities at the same rate as in-network facilities. This means your health insurance plan cannot require you to pay more for having received emergency services at an out-of-network facility. Relatedly, plans cannot require prior authorization for out-of-network emergency services.
Further, the NSA bans out-of-network facilities from balance billing patients for emergency services. Thus, facilities may not charge a patient more than their in-network cost sharing amount. This means that if you pay a 20% coinsurance for in-network emergency services, you cannot be required to pay more than a 20% coinsurance for out-of-network emergency services, regardless of the actual amount charged by the out-of-network facility.
Finally, the NSA mandates that a patient’s payments for out-of-network emergency services be applied towards their annual out-of-pocket maximum. Such changes give patients the freedom to seek emergency services without fear that their doing so will create for them a secondary financial emergency.
Non-Emergency Care from Out-of-Network Providers at In-Network Facilities
Surprise medical bills also arise in non-emergency contexts. For example, a patient may exercise due diligence by selecting an in-network facility and an in-network principal provider for a non-emergency surgery. However, the patient is not usually at liberty to select the ancillary providers that routinely assist in such operations, such as the anesthesiologist. Despite working at the in-network facility, the ancillary provider may not work for the in-network facility, but rather bill independently and thus may be out-of-network.
The NSA bans out-of-network charges for services rendered by an out-of-network provider at an in-network facility. Likewise, under the NSA, the facility cannot balance bill a patient the difference between the actual amount charged for the out-of-network provider’s services and the amount paid by insurance.
Out-of-Network Air Ambulance Services
The NSA further bans the practice of balance billing for out-of-network air ambulance services, regardless of whether such services are rendered on an emergency or non-emergency basis.
Protections for Uninsured or Self-Paying Patients
The NSA has further implications for patients without insurance or self-paying patients who choose to pay their medical bills out-of-pocket instead of submitting them to insurance. Under the NSA, these individuals are now able to get a good faith estimate of the cost of specific medical services before the services are rendered. These estimates are made available once the service has been scheduled, but they can also be made available sooner upon request. An example of an NSA-compliant good faith estimate is available here.
Additionally, if the actual medical bill ends up being at least $400 more than the estimate, the NSA permits the patient to formally dispute the charge. (Notably, this formal dispute process is in addition to any informal negotiations to resolve the dispute between the patients and the facility, itself.) To determine whether your bill is eligible for this dispute resolution process, you can visit this website. Importantly, you must dispute the charge within 120 days of the date on your bill. Additional details regarding the dispute resolution process are available here.
No one likes surprises, especially when they come in the form of medical bills. Now, the NSA protects patients from receiving surprise medical bills from out-of-network providers and facilities they never choose in the first place. Likewise, the act’s transparency provisions help uninsured and self-paying patients make financially informed decisions about their medical care.
If you need assistance with a surprise medical bill, or want to know how the No Surprise Act applies to you, please contact our office at 608-257-0040 to speak with one of our experienced attorneys.
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