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A Comprehensive Overview Of The No Surprise Act

A Comprehensive Overview Of The No Surprise Act

Introduction:

Medical debts are frequently caused by an accident or a sudden illness. Consumers are rarely notified in advance about the costs of health care treatment. When you obtain a medical bill, you may not understand whether you received the billed treatment, the correct amount was billed, the amount is covered by health insurance, and the amount has been paid in part or in full.

Understanding The No Surprises Act

No Surprises Act protects patients from surprise medical bills under some conditions. According to CMS.gov, The No Surprises Act protects people covered under group and individual health plans from receiving surprise medical bills when they receive most emergency and non-emergency services from out-of-network providers at in-network facilities from out-of-network air ambulance service providers. It also promotes healthcare cost transparency and holds patients liable solely for in-network cost-sharing levels. President Donald Trump signed the Consolidated Appropriations Act of 2021 into law on December 27, 2020 and this legislation includes the No Surprises Act, which was enacted on January 1, 2022. These measures were supposed to address unforeseen gaps in insurance coverage that arise in “surprise medical bills” when customers receive medical services from physicians and other providers outside their health insurance network without any information.

What Is Surprise Medical Billing?

A surprise medical bill is an unusual bill, usually for treatment provided by an out-of-network healthcare professional or institution that you were unaware of until you were charged. That could have resulted in increased costs than if you had received care from an in-network provider or institution. When a practitioner sends a bill to a client to cover the gap between what the insurance plan promised to pay the provider and the full-service cost, this is known as balance billing. An unexpected medical bill is also known as a surprise bill.

How Does The No Surprises Act Protect You Against Surprise Billing?

If you have a group health plan or individual health insurance coverage, The No Surprises Act (NSA) protects you from surprise billing and prevents:

  • An out-of-network provider or facility renders emergency services bills without prior authorization.
  • Out-of-network costs such as coinsurance or copayments, applies including all emergency as well as some non-emergency services.
  • Out-of-network charges and balance bills for additional care provided by out-of-network providers who work at an in-network institution, such as radiology or anesthesiology.
  • The No Surprises Act also requires some health care facilities and providers to reveal Federal and State patient protections against balance billing and establishes complaint procedures for violations of those protections.

If you do not have health insurance or pay for care without the use of your health insurance, you will be given a “good faith” estimate of the cost of your care before you receive it.

What Is Good Faith Estimate?

The Good Faith Estimate is another element of the No Surprises Act. While removing balance billing protects people with health insurance, the Good Faith Estimate criterion protects the uninsured or people who may choose to self-pay for a specific service or treatment.

The Act requires that people without insurance or self-pay patients receive an estimated cost of care before treatment or service begins. The No Surprises Act does not apply to every unexpected out-of-network bill and is restricted to emergency care, post-stabilization care, and some non-emergency care. As a result, balance bills can still be sent by providers or facilities that would provide non-emergency care that is not protected by the No Surprises Act’s definitions (for example, outpatient mental health providers or services delivered to a physician’s office).

A Good Faith Estimate informs patients of the expected cost of any offerings or treatments provided by a healthcare professional. The estimate is aimed at a patient who perhaps does not have insurance or chooses not to use insurance to pay for behavioral health services. While estimate must be made in good faith, it does not have to be ideal or properly representing care costs. There could be some difference between the estimated and actual cost of treatment. Uninsured or self-pay patients have the right to a Good Faith Estimate even if their expenses are likely zero. 

For example, an institution that includes the cost of patient care through grants must still provide patients with an estimate because there is a possibility that charges will not be zero.

How Does Healthcare Transparency Improve with The No Surprise Act?

In three ways, the No Surprises Act increases transparency:

  • It involves both parties providing patients with reasonable cost estimation before providing healthcare services.
  • It requires insurers and providers to keep up to date with provider directory information.
  • It demands that insurers reveal in-network and out-of-network deductibles and out-of-pocket maximums.
Do These Protections Apply To Protect Me If I Don’t Have Health Insurance Through Any Policy?

Persons are already protected from unexpected medical bills from providers and facilities participating in programs like Medicare, Medicaid, or TRICARE coverage or if they receive care through the Veterans Health Administration. These health insurance programs protect against unexpected medical bills.

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