The No Surprises Act: What Patients and Providers Need to Know

By: Carly J. Dziekan

Effective January 1, 2022, the No Surprises Act bans most unexpected medical charges from out-of-network providers. The new federal law saves patients the stress of receiving a high bill when they receive emergency care or scheduled treatment from out-of-network doctors and hospitals they did not choose. The No Surprises Act establishes federal protections for patients from unanticipated, costly, and burdensome medical bills.

What is covered?

The act covers most emergency services provided in hospitals, freestanding emergency departments, urgent care centers, and air ambulatory services. The act does not cover ground ambulatory services. Prior to the act, a patient would present to an emergency room for treatment for injuries sustained in a motor vehicle accident. Later, the patient received a $1,000 medical bill associated with out-of-network charges during the hospital visit. Patient’s will no longer be responsible for these additional charges.

Additionally, the act covers out-of-network charges for non-emergent care at in-network facilities. For example, a patient visits her in-network primary care physician for treatment of back pain and the physician orders an MRI. The MRI is eventually read by an out-of-network radiologist. The patient is now only responsible for the in-network charges associated with this treatment, such as a copay or deductible. Prior to the No Surprises Act, the patient was responsible for the out-of-network charges associated with the radiologist.

However, a patient may still elect to receive treatment from an out-of-network provider. If a patient chooses an out-of-network provider, for example, a particular orthopedic surgeon, the provider must notify the patient of their out-of-network status and provide an estimated bill 72 hours in advance. Then, the patient must provide consent. If the provider does not do so, they cannot bill the patient for the out-of-network charges. The act places the burden of disclosing out-of-network status on the provider and provides transparency to patients prior to treatment what the additional medical bills may be. Many patients may have already received notice from out-of-network providers they previously treated with providing them with the information required under the new law.

Lastly, the federal act applies to private health plans offered by employers and individual plans bought on or off the Affordable Care Act exchanges across the United States. Medicare and Medicaid already prohibit billing patients for the balance of their out-of-network charges.

Who pays the bill?

The law created a system where insures and providers negotiate over the bill associated with the out-of-network charges. If they cannot agree, the bill will be settled through an independent dispute resolution process. The arbitration process will consider median in-network price, while also considering the patient’s condition, the doctor’s expertise and training, market shares, and previous efforts to reach an agreement. More information about the specific implementation of this act will likely come to light in the coming months.

Next Steps

If patients receive a bill for out-of-network charges for care provided in 2022, they should contact their health insurer for clarification and potentially contest the charge. The act created a complaint process for violations. Patients should also be on the lookout for letters, emails, or other communication from physicians or hospitals regarding out-of-network status. Providers should also be aware of these changes and ensure they are providing the required notice to guarantee full payment for services.