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The No Surprises Act (“NSA”) is a federal law that was enacted under the Consolidated Appropriations Act. The NSA protects patients from unexpected medical bills occurring in emergency situations or when they receive care from out-of-network providers at the facilities of in-network providers. This type of billing is commonly referred to as “surprise billing.” The Act prohibits out-of-network providers from directly billing patients for certain services and instead requires them to seek payment from the patient’s health plan. If a patient is uninsured or opts for self-pay for a service, the NSA’s protections often provide the opportunity to get a good faith estimate of the cost of care up front.
The Difference Between In-Network and Out-of-Network Providers
In-network providers and out-of-network providers are differentiated by having a contract with a patient’s health insurance plan. In-network providers have contracts with the patient’s plan that have set rates for services, and patients typically pay lower out-of-pocket costs such as copayments, coinsurance, and deductibles. Out-of-network providers do not have contracts with the patient’s plan and can charge higher prices. In this situation, balance billing often arises, which refers to when a provider bills a patient for the difference between the provider’s charge and the amount covered by insurance.
Before the NSA, patients often unknowingly received care from out-of-network providers despite going to in-network facilities. For example, a patient could have surgery at an in-network hospital but later receive a large out-of-network bill from the anesthesiologist or radiologist who was not part of the insurance network. The NSA eliminates this problem in most emergency and certain non-emergency situations by ensuring patients are only responsible for in-network cost-sharing, even if some providers involved in their care are out-of-network.
When Does the NSA Apply?
The NSA applies in specific healthcare situations to protect patients from unexpected medical bills. More specifically, the NSA applies when:
- Emergency services are received, regardless of whether the facility or provider is in-network
- Non-emergency services are received at an in-network hospital or ambulatory surgery center with some of the providers involved being out-of-network (Ex: anesthesiologists, radiologists, etc.).
- Air ambulance services are received from an out-of-network provider
Requirements for Providers and Insurers
First, providers must give uninsured or self-paying patients a good faith estimate of expected charges before delivering the services. Second, patients must be informed and consent to receiving out-of-network care in certain situations. These situations involve non-emergency services being provided by an out-of-network provider at in in-network facility, but only when the provider is not an ancillary provider and wants to bill the patient more than the in-network cost-share. If valid consent is not received in these situations, the provider must comply with in-network cost-sharing rules and cannot balance bill the patient.
Conclusion
The NSA constituted a major shift in the healthcare billing landscape and placed the burden of payment disputes on insurers and providers rather than patients. By establishing clear limits on patient financial responsibility and instituting a dispute resolution mechanism, the Act seeks to create greater predictability and transparency in medical billing.
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Jamaal R. Jones is a Health Law Attorney at Jones Health Law P.A. where he represents healthcare practitioners and facilities in healthcare transactions, regulatory compliance, and licensing matters, healthcare litigation. He is an adjunct professor with the University of Tennessee where he teaches health law compliance. Jamaal is the Immediate Past-Chair of the Health Law Section of the Florida Bar and Vice Chair of Physician Organization Practice Group for the American Health Lawyer’s Association. He also has a YouTube page and Podcast aptly called “Jones Health Law” where he discusses healthcare law issues and interviews healthcare practitioners. (305) 877-5054; @joneshealthlaw; jrj@joneshealthlaw.com
