The No Surprises Act was passed by Congress and signed into law on December 21, 2020, as part of the year-end coronavirus economic relief package.
The Act aims to protect patients from unexpected “surprise billing.” Many of the details are still being worked out by the various government agencies, however we’ll continue to provide more information as it becomes available.
What Is “Surprise Billing”?
Surprise billing commonly occurs when a patient is treated by an out-of-network professional or is treated at an out-of-network facility. This can happen during emergency situations such as when a patient is taken to an out-of-network emergency room or is transported by air ambulance.
Surprise billing can also occur in non-emergency situations, such as an out-of-network anesthesiologist treating a patient at an in-network facility. Typically, in these cases, it is only after services are provided and a bill or benefit statement is received, that the patient discovers that the anesthesiologist was an out-of-network provider.
The patient then is faced with an unexpected “surprise” bill from the out-of-network provider seeking to recover the balance from what the health plan paid to what the out-of-network provider charged. The amount of these surprise bills can be substantial.
When Does The Law Go Into Effect And What Does It Do?
Starting January 1, 2022, the No Surprises Act generally prohibits providers from balance billing patients* for:
- Out-of-network emergency items and services
- Out-of-network non-emergency items and services provided in an in-network facility
- Out-of-network air ambulance healthcare items and services
*There are some exceptions based on provider notice and member consent.
Under the Act, a health plan (like TeamCare) reimburses the out-of-network provider an initial payment on the charges. If the provider does not agree with the payment amount, the provider has 30 days to negotiate different amount with the health plan.
Providers and health plans are provided a number of opportunities under the Act to settle on a payment amount. If reimbursement cannot be settled upon, then either the provider or health plan may invoke arbitration. In arbitration, both parties submit a proposed payment for the services, the arbitrator then must select one proposed payment, with no ability to split the difference between the two proposals.
What’s It Mean To Me?
Generally, the Act prohibits out-of-network providers or facilities from balance billing patients in emergency and certain nonemergency settings, including out-of-network air ambulances but not ground ambulance transport.
As part of this Act, TeamCare will be mailing new ID Cards to members at the end of the year. TeamCare will continue to communicate information on the Act as it becomes available. Keep an eye out for further editions of TeamCare Connections and on our website at MyTeamCare.org.