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Don’t Let the No Surprises Act Surprise You

The No Surprises Act and related regulations will come into enforcement January 1, 2022. Many of the new requirements and restrictions significantly affect healthcare providers and insurers. In a recent article published by the Heath Care Compliance Association's monthly periodical Compliance Today, Christopher Goforth, Kevin Pasciak, and Chris Tonellato discussed the impact the law will have on the healthcare industry.

Overview

After years of deliberation, the federal government enacted the No Surprises Act (the act) into law as part of the Consolidated Appropriations Act of 2021 (Omnibus legislation). The act is a consumer protection law that seeks to prevent unanticipated medical bills for patients who lack meaningful choices in providers for certain services. Out-of-network providers and facilities generally charge higher rates for items and services than in-network providers/facilities. As such, the cost-sharing obligations of patients for out-of-network items and services increase accordingly. Balance billing (sometimes called surprise billing) is a medical bill from a healthcare provider billing a patient for the difference between the total cost of services being charged and the amount the insurance pays. Balance billing by out-of-network providers occurs in both emergency and non-emergency settings, and it can have an immense financial impact on patients. The act aims to protect patients from the most prevalent types of items/services that patients receive balance bills for by reducing these out-of-network bills. The law mandates the coverage of certain out-of-network bills, limits the cost-sharing amount that individuals can be held liable for out-of-network items and services, and details requirements for providers and health plans to promote charge rate transparency.

Takeaways

  • The No Surprises Act provides new restrictions on balance billing at the federal level.

  • Patients now have a federal right to balance billing notice and consent in advance of certain treatments and/or services.

  • A new payment dispute process for some claims will affect payment rates and time frames.

  • Providers and payers operating in states with existing balance billing laws must reconcile those requirements with the act, as the more stringent standard will apply.

  • Noncompliance with the act is subject to federal enforcement, effective January 1, 2022.

Please download the PDF of the full article below.

This article was originally published in Compliance Cosmos. Copyright 2021 Compliance Today, a publication of the Health Care Compliance Association (HCCA).

© Copyright 2021. The views expressed herein are those of the author(s) and not necessarily the views of Ankura Consulting Group, LLC., its management, its subsidiaries, its affiliates, or its other professionals. Ankura is not a law firm and cannot provide legal advice.

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healthcare compliance, compliance, healthcare operations, government & public sector, article, healthcare & life sciences, f-risk, f-performance