At the beginning of 2022, the “No Surprises” Act was enacted. Officially, it is part of the Consolidated Appropriations Act of 2021, which aims to eliminate a large majority of “surprise” medical bills. These typically occur in emergency situations where the ability to guide the patient towards in-network is not feasible due to urgency or location.1 For the provider, there are a series of regulations that apply to them and their practices.2

  • No balance billing3 for out-of-network emergency services4
  • No balance billing for non-emergency services by out-of-network providers during patient visits to certain in-network health care facilities, unless notice and consent requirements are met for certain items and services.
  • Providers and health care facilities must publicly disclose patient protections against balance billing
  • No balance billing for covered air ambulance services by out-of-network air ambulance providers
  • In instances where balance billing is prohibited, cost sharing for insured patients is limited to in-network levels or amounts
  • Providers must give a good faith estimate of expected charges to uninsured and self-pay patients at least 3 business days before a scheduled service, or upon request
  • Plans, issuers, providers, and facilities must ensure continuity of care when a provider’s network status changes in certain circumstances
  • Plans, issuers, providers, and facilities must implement certain measures to improve the accuracy of provider directory information

Exceptions to the Rule(s)

These regulations do allow important exceptions in certain cases.5 For example, the second rule above permits balance billing in the following case2:

Out-of-network providers and out-of-network emergency facilities may balance bill for post-stabilization services only if all of the following conditions have been met:

The attending emergency physician or treating provider determines that the participant, beneficiary, or enrollee:

  • Can travel using non-medical or non-emergency medical transportation to an available in-network provider or facility located within a reasonable travel distance, taking into account the individual’s medical condition; and
  • Is in a condition to receive notice and provide informed consent;
  • The out-of-network provider or out-of-network emergency facility provides the participant, beneficiary, or enrollee with a written notice including certain information during a specific timeframe (as provided in regulations and guidance) and obtains consent to waive surprise billing protections; and
  • The provider or facility satisfies any additional state law requirements.

There are other significant allowances throughout the act that are too lengthy to list for this blog. There are also rules that have no exceptions, specifically with the fourth rule for air ambulances and two others.2

How You Practice, Rather Than What

Another interesting component of the act is that “when assessing whether a No Surprises requirement applies to a particular provider, it is important to look at how the provider practices, rather than the provider’s specialty type, license, or certification. The rules apply broadly to any physician or other health care provider who is acting within the scope of practice of that provider’s license or certification under applicable state law.2

Guarantee No Surprise with the No Surprises Act

With all the regulations and exceptions to them, it can be easy to violate them accidentally. Questions about the provider requirements can be sent to Advantum Health also has resources and experts available to navigate the No Surprises Act, as well as the myriad other government regulations that can be so daunting and time consuming to a provider’s staff. Contact us today to learn how we can help lighten your regulatory burden.