MEDICAL BILLING
NO
SURPRISES
ACT
BY CANDACE ARVIN
CANDACE ARVIN , EMPLOYEE BENEFITS ADVISOR , GENERAL INSURANCE SERVICES
Have you ever received a surprise medical bill from a provider you did not designate ? This often occurs when consumers seek care at an in-network hospital only to later find out that not all providers within that hospital share in the same network agreement . According to a study from Peterson-KFF , this occurs in about 1 in 5 emergency room visits and between 9 % and 16 % of in-network hospitalizations for non-emergency care . The good news is you are now protected from this kind of inadvertent billing . The No Surprises Act ( NSA ), which took effect in 2022 , establishes federal protections against surprise medical bills . Surprise medical bills arise when insured consumers unwittingly receive care from out-ofnetwork hospitals , doctors , or other providers they did not choose .
Surprise billing places a significant financial burden on consumers , especially when health plans deny out-of-network claims or apply higher out-of-network cost sharing .
The NSA protects consumers by :
• prohibiting doctors , hospitals , and other covered providers from billing patients more than the in-network cost sharing amount for surprise medical bills ; and
• requiring private health plans to cover these out-of-network claims and apply in-network cost sharing .
The law applies to both job-based and non-group plans , including grandfathered plans .
UNDER THE NEW LAW : BALANCE BILLING IS PROHIBITED .
This occurs when a provider bills you for the difference between the provider ’ s charge and the allowed amount . Out-ofnetwork providers for emergency services are not allowed to “ balance bill ” patients beyond the applicable in-network cost sharing amount for surprise bills . This also goes for out-of-network providers who render non-emergency services at an in-network hospital or other facility .
Health plans must cover surprise bills at in-network rates . The law now requires private health plans to cover surprise medical bills for emergency services as well as out-of-network provider bills for services rendered at in-network hospitals and facilities .
COVERAGE FOR EMERGENCY SERVICES WITHOUT PRIOR AUTHORIZATION .
Surprise bills must be covered without prior authorization , and in-network cost sharing must apply . In-network cost sharing for surprise bills will be based on a “ recognized amount ,” which in most cases will be the median in-network payment amount under the plan for the same or similar services .
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