What is the No Surprises Act?

The No Surprises Act (NSA) went into effect on January 1, 2022, protecting patients from surprise medical bills after treatment and requiring Good Faith Estimates (GFEs) for uninsured and self-paying patients.

Where the NSA is Located – the Consolidated Appropriations Act (2021)

On December 21, 2020, the Consolidated Appropriations Act (2021) was passed by Congress and signed into law on December 27^th. At 5,593 pages in length, it’s the longest bill yet in US history and included $900 billion in COVID-19 relief.

At the end of the bill, added provisions include a section, “Division BB‑Private Health Insurance and Public Health Provisions.” Titles 1 and 2 of the division, “No Surprises Act” and “Transparency,” cover patient-consumer protections and transparency in healthcare, including pricing transparency.

What the NSA Covers

The No Surprises Act outlines a ban on surprise medical billing for anyone covered by group and individual health plans when receiving:

• most emergency services
• non-emergency services at in-network facilities by out-of-network providers
• out-of-network air ambulances

What’s a Surprise Medical Bill?

“Surprise” medical bills are sent to patients, post-treatment, by out-of-network (OON) providers, where the patient is responsible for covering the financial responsibility. Some states already have protection against surprise billing in place. In some instances, a patient’s insurance will cover part of an OON provider’s fee, and the provider will then bill the patient for the remainder of their fee. This is known as “balance billing,” and is also considered a surprise bill.

Payors and Providers and the Independent Dispute Resolution

In connection with surprise billing, the NSA details the independent dispute resolution (IDR) where providers and payors submit payment offers to an IDR arbitrator within a specific timeframe, using a determined Qualifying Payment Amount (QPA); the payor’s median contracted rate for a similar service and specialty.

The Patient’s Side

OON providers cannot balance bill patients unless the patient has signed a consent form, waiving their rights to protection.

Patients are still responsible for co-pays, co-insurance and their deductibles, which must be billed as if the provider were in-network and is considered the patient’s cost-sharing amount. Paid cost-sharing amounts are applicable towards deductibles and out-of-pocket limits.

For more information, see “No Surprises: Understand Your Rights Against Surprise Medical Bills.”

Providing Patients with Good Faith Estimates

When a patient does not have health insurance or when a patient chooses to not use health insurance, they must be provided with a good faith estimate either when scheduling an appointment or when requesting a GFE.

The GFE must be given electronically or on paper according to the patient’s preference, and in person or by mail when the patient does not have a mailing address. CMS has information on what must be included on a GFE.

Providers must post a notice on their website and in the office about patients’ rights to a GFE, and the information must be given to a patient when questions around cost come up.

For more information on the No Surprises Act, Good Faith Estimates and pricing transparency, visit the Clearwave No Surprises Act Resource Center.

For more information on how a bill becomes a law, please see this gem.