On January 1, 2022, the federal No Surprises Act went into effect, intended to reduce “surprise bills” being sent to patients for services rendered at hospitals and surgery centers, as well as physicians providing services at those facilities. These healthcare providers must immediately take steps to be compliant with the Act.
The definition of a “surprise bill” is one that the patient receives for services from a healthcare provider that the patient was not aware was out-of-network with the patient’s insurance company. These bills are often involved with an emergency room visit or other services where an out-of-network provider performs work at an in-network facility.
In general, the Act prohibits:
- Surprise billing for emergency services, no matter where they are provided, must be treated as in-network without prior authorization;
- Out-of-network charges an auxiliary caregiver (i.e., pathologist or anesthesiologist) at an in-network facility, no matter what the circumstances;
- Out-of-network charges for a surgeon or for other primary caregiver services without notifying the patient and securing patient consent;
- Out-of-network cost-sharing for emergency or non-emergency healthcare services without patient consent.
The Act requires a consumer notice in plain language to patients regarding:
- restrictions on balance billing for services allowable under the Act;
- pertinent state law balance billing restrictions that may apply; and
- contact information for relevant state and federal agencies with which the consumer may file a violation complaint.
Finally, the Act provides the following exception out-of-network billing: emergency medicine; radiology; neonatology; diagnostic testing; pathology; anesthesiology; and services provided by hospitalists, intensivists, and assistant surgeons.
Authored by Anita Wing with Karen McKeithen Schaede
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