No Surprises Act
Did you know that 1 in 5 patients receive surprise bills after receiving medical care? Why does this happen? It often happens because you receive treatment from medical professionals outside of your insurance network. Even if you are at an “in network” hospital, for example, the hospital may utilize “out of network” doctors. And of course, you don’t select every doctor in a hospital providing your treatment. The good news is that the No Surprises Act (NSA) allows you to dispute these fees. Our federal government estimates that the NSA will apply to ten million of these surprise bills annually. This article reviews the No Surprises Act. It also outlines the instances when the No Surprises Act can be effective and when you can challenge medical bills. If you receive a health insurance denial, reach out to the Law Offices of Scott Glovsky for help.
What Are Surprise Bills?
Surprise bills are bills that indicate a patient received treatment from a practitioner outside of their insurance company’s network. Out of network treatment is care provided by a facility or practitioner not covered by or partnered with a patient’s insurance company. Although patients may receive treatment at a hospital that is in-network, the hospital may employ anesthesiologists, radiologists, emergency room doctors, and others who are out of network. These out of network care providers then charge the patient for the treatment they provided. The difference between what the insurance covers and what the practitioner charges is known as “balance billing.”
What Does It Mean to Be “In-Network”?
If you have health insurance, “in-network” means a provider or facility is inside of your plan’s network. Inside the network typically means that the health insurance company has negotiated a rate that a provider or facility can charge for services. The benefit of using an in-network provider or facility is usually related to cost because they can only charge you the negotiated rate. Another cost factor is that the insurer may pay a higher percentage of the charges for in network providers. In other words, your out-of-pocket costs will be lower. Finally, many health insurers have different deductibles for in network and out of network services. So, if a policyholder is close to meeting an in-network deductible, this person has an incentive to keep using in network providers.
What Is the No Surprises Act?
Enacted on January 1, 2022, the No Surprises Act serves to protect patients from these surprise bills. The NSA requires private health plans to cover out-of-network fees and to apply in-network cost sharing. (In network cost sharing is the amount a facility or provider bills when it is in network.) The NSA also prevents medical providers including doctors and hospitals from billing patients more than the in-network cost sharing amount. In other words, the NSA caps the amount you’re charged. (If you have Medicare, Medicaid, TRICARE, or get care through the Indian Health Services or Veterans Health Administration, you already enjoy the protections provided by the NSA.) The act also governs how health insurance companies reimburse out of network providers. And it regulates how disagreements between the two get resolved. Federal and state laws have different benchmarks for determining a “reasonable amount.”
What Types of Medical Services Does the No Surprises Act Apply To?
The act applies to emergency services including hospital ERs and urgent care facilities that provide emergency services. It covers air ambulance transportation but not ground ambulance transportation. The NSA also covers post-emergency stabilization services which include those up until the time a patient can go to another facility without a medical transport. Finally, the act covers non-emergency services provided at in network facilities. This includes going to an in-network hospital that has out of network care providers.
A good rule of thumb is to always check with your health insurer prior to receiving services. Ask if a provider or facility is in network because your cost will usually be lower. And remember that the No Surprises Act doesn’t apply to physician’s offices, urgent care clinics that aren’t providing emergency services, and many other situations.
In terms of ground ambulances, some states protect individuals from surprise bills. In California, as of January 1, 2024, AB 716 prevents some surprise out-of-network ground ambulance bills. Applying to state-regulated insurance plans, the law says that out-of-network ambulance companies must bill the same amount as in-network companies. And uninsured individuals cannot be charged more than the Medi-Cal or Medicaid rate (whichever is more). The law also bans ambulance companies and debt collectors from taking legal action against patients for at least a year after the initial bill.
How Does the No Surprises Act Work?
The No Surprises Act created a process for determining the payment amount for surprise bills, setting a precedent for the presence of negotiations. If negotiations fail, the NSA established an independent dispute resolution (IDR) process. When a patient receives services protected under the NSA, providers cannot charge patients more than their in-network cost sharing amount. Medical providers who violate this act can receive a fine of up to $10,000 for each violation.
How Do I Know If My Bill Is a Surprise Medical Bill?
Both health insurance companies and health providers must tell patients about consumer surprise medical bill protections. Health care providers are required to post and give patients a disclosure about NSA protections. The health insurance company must provide this disclosure with its Explanation of Benefits (EOBs).
If the health insurance company or health provider doesn’t give the disclosure, a patient must identify the surprise bill. Always look for bills from out of network providers. For example, look at a date of service for your medical care and identify if there are bills from both the facility and other practitioners. If a bill seems overly expensive or otherwise odd, call your health insurer and ask about it. You can also reach out to the No Surprises Act Help Desk at the number listed below.
What If I Don’t Have Insurance or Want to Pay with Cash?
The No Surprises Act sets a precedent for fair payment even if you are uninsured or pay cash. The act requires that all medical service facilities and providers give “Good Faith Estimates” to patients. Good faith estimates should be reliable and accurate. The providers need to give them when patients schedule a service or request cost information. The estimates must also include charges from “co-providers” for services that occur together with the primary service. These estimates give you a general ballpark of what they’ll charge for their services. And if the provider charges $400 or more beyond your good faith estimate, you can dispute the bill.
Can a Medical Provider Ask Me to Waive My Rights Under the NSA?
Some medical providers will ask patients to waive their rights to NSA protections via a “Surprise Billing Protection Form.” A patient must voluntarily sign the waiver. However, there are situations where providers may not utilize waivers. These circumstances include emergency services and unknown urgent needs during non-emergency care. These settings also include services related to emergency care such as an out-of-network provider at an in-network hospital. Waivers are not allowed for assistant surgeon services or diagnostic services. Finally, waivers aren’t permitted for out of network providers when no in network providers are available at a facility.
Be careful if a medical provider demands a signature on a waiver. This waiver gives practitioners or facilities the right to charge you more for their services. If you decide to waive your right to NSA protections, a few things should happen. A provider should give you a good faith estimate of the charges for their service along with the waiver. And it should give you a list of in network providers so you’re informed of your options.
If you feel you have no choice because you have an emergency and they won’t treat you without your signature, then do a few things. Add notes to the form that you don’t think the facility or provider is legally allowed to give you this form. Make sure to take a picture of what you wrote and what you signed. Then report it to the NSA hotline or file a complaint (see below).
What if a Provider, Facility or Health Insurer Doesn’t Comply with the No Surprises Act?
The Good Faith Estimate and Patient-Provider Dispute Resolution provisions allow a patient to request an independent resolution if the charges exceed the estimate by $400 or more. (Remember there may be multiple providers for a single procedure and the provision applies to each estimate.) And this provision applies to all medical service providers – even those who usually don’t take insurance. As such, this process applies to cosmetic surgeons, fertility clinics, mental health providers, weight loss surgeons, and others.
If a health insurance plan denies or applies out of network cost sharing to medical bills, a policyholder must first appeal this decision to the insurer. If the decision stands, then the policyholder can appeal to an independent external reviewer. You have 120 days to file a dispute claim. To submit a complaint, you can go here.
There is also a number you can call to report provider and facility violations. The No Surprises Help Desk number is (800) 985-3059. Health and Human Services (HHS) must respond within sixty business days but may start preliminary reviews within a week.
Another place to turn is the state ombudsman programs or Consumer Assistance Programs (CAPs). The Affordable Care Act created CAPs. They help policyholders understand their coverage and rights and can help you resolve issues. Health Access, California’s Health Consumer Advocacy Coalition, also helps with complaints.
Health Insurance Denial and the No Surprises Act
No one wants a health insurer to deny medically necessary treatment that doctors say they need. But sometimes the provider or facility is out-of-network. And when they are out-of-network, your health insurance company may balance bill you for the difference between what they cover and what the provider charges. You can take a few steps to help ensure you are more fully covered. First, you may seek a provider or facility that is in network. Alternatively, you may seek an exception for this provider or facility if they are the only ones who can offer the treatment you need. Doing so will prevent balance billing.
And just like you can appeal a medical necessity health insurance denial, you can now appeal surprise bills to an external review board.
Has the No Surprises Act Changed Since It Was Implemented on January 1, 2022?
Yes, the NSA has changed a bit since January 2022. However, the changes do not impact patient protections. Instead, they relate to how payments are determined between health insurers and providers.
The Texas Medical Association challenged the federal government’s surprise medical billing rules relating to the arbitration process for establishing payment to out-of-network providers. The NSA determined the payment amount should be close to the median rate that health plans pay to in network providers in a geographic area. This method is known as the “qualifying payment amount” or “QPA.” A federal judge in Texas ruled in favor of the association regarding the rule that instructed arbitrators in the Independent Dispute Resolution (IDR) process to adhere to the QPA. This ruling also limited the use of other statutory factors.
Some therapists asked for an exemption from the good faith estimate for routine mental health services. The reason is that it is difficult to know the mental health diagnosis before therapy begins. Plus, it is difficult to know what the course of treatment will be and how long it will last.
In October 2023, HHS, the departments of Labor and Treasury and the Office of Personnel Management proposed a new rule to better resolve surprise billing issues between health insurance companies and providers. Among other things, the new rule would mandate more information sharing, lower fees, set deadlines, and create Independent Dispute Resolution eligibility rules.
Is The No Surprises Act Working?
Fortunately the No Surprises Act is working. It prevented 9 million surprise bills in the first nine months of 2022. And according to a January 2024 report from the Blue Shield Blue Cross Association and the health insurance trade association AHIP (America’s Health Insurance Plans), it prevented 10.1 million surprise bills from January through September 2023. This figure represents 0.7 percent of total commercial claims processed by health insurers. A February 2024 whitepaper from FairHealth found that from the first quarter of 2019 to the third quarter of 2023, in-network claims as a percent of all claims grew 7% nationally. In the same period, in network claims in emergency healthcare grew 13.2%. Perhaps best of all, in this time frame, allowed amounts as a percentage of billed amounts for in network healthcare decreased by 14.3%.
Contact Law Offices of Scott Glovsky if You Receive a Health Insurance Denial
The Law Offices of Scott Glovsky has been representing injured consumers and health insurance denial victims since 1999. We focus on health insurance bad faith, catastrophic personal injury, sexual abuse, and consumer-related litigation. We get justice for our clients and hold the wrongdoers accountable.