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What is the "No Surprise Act"?

By Martine G. Brousse (not AI!)

"The Medical Bill Whisperer"

Patient Advocate, Certified Mediator

AdvimedPro

 

May 28, 2024

 

The federal “No Surprise Act” (aka “NSA”) has changed the face of healthcare in the short time since January 2022, when it was enacted.

 

So what does it do exactly, what does it mean for patients and what should we be aware of?

 

A.   First, some definitions:

 

1.     “In Network”:

·      the medical provider, facility or independent professional, has a contract with your insurance/plan.

·      the provider gives your insurance and its members a discount, or adjustment, reducing the bill

·      the cost to the patient will be the lowest, as the insurance will pay the highest rate

 

2.     “Out Of Network”:

·      the medical provider, facility or independent professional has NO contract with the insurance/plan

·      the provide gives the insurance and the patient NO discount, NO adjustment, NO reduction of the bill

·      the cost to the patient is the highest, as the insurance pays little or nothing at all

 

3.     “Facility

·      It is the brick and mortar building where medical services are rendered. Under the terms of this law, “facility” usually means: ER department, hospital, medical clinic, surgicenter, psych hospital, behavioral treatment center, dialysis center, infusion center, urgent care, skilled nursing facility etc

 

4.     “Surprise Bill”

·      These are bills you might receive from an out of network provider, and whose total cost you are responsible for, even if:

  • you did not hire or seek the services from that OON provider

  • you did not have a choice of an In Network provider

  • you did not even know they were providing services (i.e. pathologist, radiologist)


5.     “Balance billing”

·      The right an OON provider has to bill any patient for the difference between the fee for a service, and whatever amount may have been paid by the insurance.

·      If the insurance has not paid anything, then the full amount billed can be “balance-billed” to the patient even if:

  • you did not hire or seek the services from that OON provider

  • you did not have a choice of an In Network provider

  • you did not even know they were providing services (i.e. pathologist)

 

B.    Why this law matters:

 

1.     It protects patients from receiving “surprise bills”, or being “balance-billed” under certain circumstances:

·      When they receive services under emergency conditions

·      When they receive services from Out Of Network providers at an In Network facility

·      When they must use an out of network air ambulance service

 

2.     Patients can no longer be penalized if:

·      The facility and medical providers are Out of Network, and provide emergency service, as the insurance MUST cover the cost at the highest rate, and the facility and providers must accept that rate in return

·      For non-emergency services, the same rate and obligations apply for OON providers at an In Network facility

·      The medical providers – facility and individual professional – MUST accept that rate (lower than billed amount) and can only bill the patient if the insurance applies a share of cost

·      THIS IS HUGE!!!!

 

3.     Authorizations are no longer needed, reducing the risk of denials for lack thereof

 

C.    Be aware!

 

1.     Not all OON claims qualify!

·      If you seek or receive services from an OON provider NOT under emergency conditions and/or NOT in an In Network facility, the law does not apply.

 

2.   The law has time limits per encounter

·      If you are deemed “stable” enough, meaning well enough clinically to be transferred to an In Network facility after an ER visit at an OON facility, but refuse to be transferred, your protection will end. All claims rendered after the determination of “clinical stability” will be considered OON, billed by the provider(s) and paid by insurance as such

·      If you are “admitted” to a hospital, even In Network, following an ER visit, but do not notify your insurance, or request an “inpatient” authorization, you will lose protection as the “no authorization needed” clause only extends to the ER.

 

 3.  Waivers

·      An OON network may ask you to sign a waiver of your rights, which means you would accept to consider their fees as OON and therefore payable in full.

·      Although they are not allowed to do so if you are impaired, or within an emergency event, it is always a good thing to look twice at what you sign, or have someone else do so. A signature on a waiver could end up costing a lot!

 

4.     Liability

·      Make sure your insurance credits any liability toward your In Network share of cost, not OON, for those claims that fall under the law. Although some providers are technically OON, their claims are not by legal mandate.

 

5.     State Laws

·      Your State may already have a similar “no balance bill” law. Although it cannot override the federal mandate, it might extend it, for example to cover all ground ambulance claims as In Network.

 

6.     Appeals Rights

·      The law gives patients Appeals Rights in case they are being billed when they should not.

·      If a medical provider or facility bills you more than they should, or does not reduce their bills according to the Explanation Of Benefits (“EOB”), file a grievance with your insurance. They will contact the provider and enforce the law

·      If your insurance does not want to pay, or does not pay correctly, you can contact the federal agency responsible for enforcement: https://www.cms.gov/files/document/nsa-helpdesk.pdf or call 800 895 3059.

 

7.     Double check!

·      Errors happen, so make sure any invoice balance from a medical provider matches the liability indicated on the corresponding EOB. And make sure there is some form of adjustment on the EOB, or indication that the claim was processed In Network as it should have.

 

The No Surprise Act's impact has been swift and profound, and while medical providers, especially individual physicians and hospitalists have decried the negative impact on their income, there is little doubt of the positive effect on patients’ wallets.

This is no doubt a large victory for patients.

 

 

Martine Brousse was a long-time Billing Manager for Physicians before switching to the side of patients in 2013. The move has allowed her to apply her deep expertise and vast experience of the intricacies of resolving all types of medical bill and claim payment issues in ways that directly and positively impact her clientsʻ finances.

 


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@martine brousse 2024 @ the medical bill whisperer 2024

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