The No Surprises Act, enacted in December 2020, aims to protect patients from unexpected medical bills arising from out-of-network care. This bipartisan legislation has been designed to address the issue of surprise medical billing. It ensures that patients are not caught off guard by costly bills after receiving emergency care or undergoing scheduled procedures. With the act set to take effect in 2022, let’s take a closer look at the changes and clarifications implemented in 2023.
Background Of Surprise Medical Billing
Surprise medical billing often occurs when patients receive care from out-of-network providers, usually during emergencies or when they have little control over choosing their healthcare providers. These out-of-network providers can charge exorbitant fees, leaving patients with hefty medical bills that their insurance does not fully cover. The No Surprises Act aims to prevent this burdensome situation and provide relief to patients.
As of January 1, 2022, the No Surprises Act has been enacted to provide patients with clearer insights into healthcare costs before they receive medical care. The primary objective of this act is to shield patients from unexpected and burdensome medical bills that arise when they inadvertently receive treatment from healthcare providers who are not in their insurance network. On August 19, 2022, the U.S. Department of Health and Human Services (HHS) and the Treasury took a significant step by issuing a third final rule for the No Surprises Act. This rule was slated to take effect on October 25, 2022.
Let’s delve into how this latest final rule affects the federal independent dispute resolution process. We’ll also explore its impact on other aspects of the No Surprises Act, such as the transparency rule for healthcare payers, disclosures and notices, and regulations concerning out-of-network and no-network insurance plans.
Key Revisions in the No Surprises Act Final Rule
Commencement of Payment and Negotiations
In adherence to the final rule, federal authorities have outlined a clear process for insurers and healthcare plans. They are urged to promptly issue initial payments or provide payment denial notifications within 30 calendar days after an out-of-network healthcare provider submits a bill covered by the No Surprises Act. It’s important to note that the 30-day countdown begins once the insurer has all the necessary information for processing a clean claim.
Crucially, healthcare providers must hold off on initiating open negotiations until receiving either an initial payment or a payment denial. This rule applies even if the insurer or plan fails to meet the 30-day deadline for sending the initial denial or payment. Providers must exercise patience and await this crucial notification. Both the initial payment denial and the payment serve as triggers, starting a 30-business-day timeline during which open negotiations must commence.
Furthermore, providers can proceed with the open negotiation phase if the insurer or plan does not provide the necessary information in the initial denial or payment, provided they have waited for the initial notification.
In cases where one party fails to respond during the 30-day open negotiation period, the opposing party retains the option to initiate the federal Independent Dispute Resolution (IDR) process after this negotiation window. This ensures a fair and structured approach to resolving billing disputes under the No Surprises Act.
QPA No Longer Presumptive
One of the most noteworthy changes introduced in the final rule profoundly impacts the decision-making process within Independent Dispute Resolution (IDR). In the preceding interim final rule, IDR entities were directed to lean towards the offer closest to the Qualifying Payment Amount (QPA), with exceptions permitted if credible data demonstrated a significant deviation from the appropriate out-of-network rate
However, the newly effective final rule, which took effect on October 25, 2022, refrains from dictating which offer IDR entities should select. Instead, it significantly emphasizes the process by which IDR entities make their choices. Specifically, the final rule guides IDR entities to opt for the offer that best reflects the value of the disputed service or item. In reaching this decision, IDR entities must take into account:
Independent Dispute Resolution Fee Adjustments
In response to a growing backlog of disputes requiring eligibility determinations, significant changes have been made to the fee structure for the independent dispute resolution (IDR) process. These changes, outlined in the amended 2023 fee guidance released by CMS on December 23, 2022, became effective on January 1, 2023.
Here’s a summary of the fee adjustments:
The rationale behind this fee increase is the mounting number of disputes awaiting eligibility determinations. This has led to contractors and government personnel engaging to conduct pre-eligibility reviews and support certified IDR entities in their determination processes. A snapshot from the Federal IDR Status Update, released in December 2022, provides further insight into the situation:
Additionally, more than 600 distinct non-initiating parties were involved in disputes related to emergency and non-emergency items or services. United Healthcare emerged as a prominent participant, accounting for approximately one-quarter of all disputes. Below is a table summarizing the top five insurance providers that appeared as non-initiating parties in 85% of disputes. These disputes were concerned with both emergency and non-emergency services:
| Insurance Provider | Percentage of Disputes Involving a Non-Initiating Party |
| United Healthcare | 24% |
| Aetna | 14% |
| MultiPlan | 11% |
| Cigna | 9% |
| Anthem | 10% |
Changes in Air Ambulance Service Coverage
Under the No Surprises Act, insurance plans are not obligated to extend coverage to non-emergency situations. This could involve instances when they specifically cover air ambulance services for emergencies. In simple terms, if your plan only covers air ambulance services for emergencies, it won’t cover them for non-emergencies. However, if your insurance plan includes coverage for air ambulance services, they must also cover air ambulance services offered by out-of-network providers. This ensures that you won’t be left with unexpected bills, provided that you use an out-of-network air ambulance.
It’s important to note that the No Surprises Act doesn’t dictate the specific services that insurance plans must offer. So, if your plan doesn’t include non-emergency air ambulance services, they are not obligated to cover them. The No Surprises Act doesn’t protect patients from surprise bills in such situations.
Remarkably, even if you’re picked up by an air ambulance outside the United States, you’re still protected from out-of-network bills. Federal officials will determine the geographical region insurers and plans should use for calculating the Qualified Payment Amount (QPA). Until then, insurers and plans should employ a reasonable method. This could include methods like utilizing the U.S. border entry point after the patient is picked up. These changes simplify and clarify the coverage of air ambulance services, ensuring patients are shielded from unexpected expenses.
CMS Clarifies Scope of Non-Emergency Services Affected by the No Surprises Act
The No Surprises Act has established protections against balance billing for non-emergency services provided at specific participating healthcare facilities. These healthcare facilities, as defined by the act, encompass hospitals, hospital outpatient departments, critical access hospitals, and ambulatory surgery centers. It’s important to note that these protections are not contingent on whether the provider is physically located at the facility.
Initially, the No Surprises Act did not explicitly address non-emergency services conducted in other healthcare facilities like urgent care centers. However, on April 6, 2022, the Centers for Medicare & Medicaid Services (CMS) issued a set of Frequently Asked Questions (FAQs). It aims at providing guidance to healthcare providers regarding the No Surprises Rule. In these FAQs, CMS offered a clear clarification. CMS’s clarification ensures that defined healthcare facilities protect individuals seeking non-emergency care from unexpected balance bills. Importantly, these protections do not extend to other healthcare facilities, such as urgent care centers. This clarification from CMS ensures that defined healthcare facilities safeguard individuals seeking non-emergency care against unexpected balance bills. In contrast, those utilizing other healthcare facilities may not enjoy the same protections under the No Surprises Act.
Key Provisions of the No Surprises Act Remain Unchanged
The fundamental framework of the No Surprises Act maintains its integrity, with seven key requirements for healthcare providers remaining unchanged. These enduring provisions encompass:
It is vital to note that the Act extends its prohibition on balance billing to non-emergency services. These services could have been offered by hospitals or surgery centers.
Conclusion
The No Surprises Act is a significant step towards protecting patients from unexpected and overwhelming medical bills. As the clarifications take effect, patients can take solace in the fact that they will be shielded from balance billing. They will also be able to gain access to cost estimations for procedures and benefit from dispute resolution process. By this method, the patients will potentially be covered by even stronger state laws. As the healthcare industry continues to evolve, prioritizing patient protection and enhancing transparency becomes crucial. This will ensure they receive the care they need without enduring financial hardships.
