OUT-OF-NETWORK PROVIDERS ARE PROHIBITED FROM SENDING OUT BILLS FOR EXCESS CHARGES .
The law specifies that providers “ shall not bill , and shall not hold patients liable ” for an amount that is over the in-network cost sharing amount for such services .
DISPUTE RESOLUTION .
MEDICAL BILLING
In the event of a surprise billing , providers still get paid , and this is where dispute resolution is introduced . If your state does not have a surprise billing law or you require more detailed support , providers can utilize the Independent Dispute Resolution Process ( IDR ). This aids providers and facilities to determine how much a payor must pay an outof-network provider or emergency facility for services that fall under balance billing restrictions . On the patient side , uninsured individuals can implement a patient-provider open dispute resolution process if their bill is significantly higher than the Good Faith Estimate ( GFE ).
SPECIFIC OVERSIGHT AND ENFORCEMENT ACTIVITIES ARE REQUIRED .
Individual states may enforce federal requirements against the health plans they regulate — non-group health plans and fully insured employer-sponsored plans — with federal fallback enforcement required if it is determined that states are failing to substantially enforce the law . It is the federal government ’ s primary responsibility to provide oversight and enforcement with respect to self-insured group health plans , which today cover about half of all people with job-based coverage , and which states are preempted from regulating under the Employee Retirement and Income Security Act ( ERISA ). The Secretaries of Labor and Treasury must audit a sample of plans each year to ensure that plans are covering surprise bills and applying in-network cost sharing correctly .
So how will the NSA affect patients over the long run ? It will provide significant protections for consumers who would otherwise be forced to pay extremely high balanced bills for providers they did not have a choice in such as radiologists , pathologists , and anesthesiologists . If there is an error in a bill , the process for fixing it should be relatively simple on the patient side as the NSA aims to leave the patient out of payment disputes .
As implementation proceeds ( and as federal courts consider legal challenges to such regulations ), it is also possible that NSA standards and procedures will be modified further . If you have any questions or concerns regarding the NSA , we invite you to reach out to us . +
Candace was born and raised in Chesterton , Indiana . After graduating college with a degree in Business Administration , she spent five years working in the healthcare industry where she gained a multitude of experience serving populations ranging from pediatric to geriatric . She enjoys volunteering in the community and serves on the Hobart Chamber of Commerce Board of Directors . In her free time , Candace enjoys visits to the beach , kayaking , reading , and spending time with friends and family .
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This example is illustrative only and not indicative of actual past or future results . Stop Loss is underwritten by Berkley Life and Health Insurance Company , a member company of W . R . Berkley Corporation and rated A + ( Superior ) by A . M . Best , and involves the formation of a group captive insurance program that involves other employers and requires other legal entities . Berkley and its affiliates do not provide tax , legal , or regulatory advice concerning EmCap . You should seek appropriate tax , legal , regulatory , or other counsel regarding the EmCap program , including , but not limited to , counsel in the areas of ERISA , multiple employer welfare arrangements ( MEWAs ), taxation , and captives . EmCap is not available to all employers or in all states .
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