President Trump signed the No Surprises Act on December 27, 2020, as part of the Consolidated Appropriations Act of 2021. Sections of the new law will begin taking effect as early as January 1, 2022, and its main purpose serves to protect patients from unexpected medical bills. These new requirements will apply to individual and group health plans - self-funded and fully insured.
Under this Act, providers cannot issue unexpected or surprise medical bills on patients for emergency services that were performed at an out-of-network facility, as well as certain services from out-of-network doctors at in-network locations. Instead, patients are only liable for the amount they would pay if they were getting the emergency service at an in-network provider. There are certain exceptions to this ruling. For example, providers may charge more than the in-network amount if they inform the patient ahead of time that their service is billed at a higher out-of-network rate, and then get consent to charge that amount.
The notice and consent process does not extend to emergency services, some ancillary services, and items or services that were delivered due to an unforeseen and urgent need which arose during a procedure, even if notice and consent were given for the primary procedure.
Under these circumstances, the patient will only be liable for the in-network cost, providers and insurers can still negotiate reimbursement. Insurers have 30 days upon receiving a bill to either pay the provider or provide notice that they are denying payment. Regardless, the insurer cannot defer payment to the patient and must credit any cost-sharing toward the patient’s deductible and out-of-pocket maximum. In the event of a reimbursement dispute that cannot be resolved between the provider and insurer an independent dispute resolution (IDR) process may be triggered. Either party can initiate this process. In an IDR process a third party is appointed in conjunction by the provider and insurer. The IDR entity would then arbitrate and determine reimbursement.