No Surprises Act

The No Surprises Act was enacted in December 2020 and generally took effect on January 1, 2022. It protects patients in three situations: emergency care, including services after the patient is stabilized; non-emergency care from out-of-network providers at in-network hospitals, hospital outpatient departments and ambulatory surgical centers; and air ambulance services from out-of-network providers. In those situations the patient pays only in-network cost sharing and cannot be billed for the rest. Ground ambulance services are generally not covered.

For a practice, the law creates three jobs, and they sit at the center of out-of-network billing. The first is sorting claims. A protected claim follows federal payment rules, and some providers can never ask a patient to waive the protection: emergency medicine, anesthesiology, pathology, radiology, neonatology and diagnostic services, assistant surgeons, hospitalists and intensivists. The second is estimates: uninsured and self-pay patients get a good faith estimate before scheduled care. The third is payment disputes. When a plan’s payment on a protected claim seems too low, the provider opens a 30-business-day negotiation and, if that fails, can take the amount to independent dispute resolution.

The mistake is applying the law to every out-of-network claim, or to none. A routine office visit with an out-of-network doctor is not one of the protected situations, while an out-of-network hospitalist’s visit at an in-network hospital is. The rules also keep developing through new regulations and guidance, so check each claim’s facts before a patient statement goes out.