What to Expect From the No Surprise Act
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Gain an understanding of surprises balance billing, the problems it causes, and the ways the No Surprises Act attempts to address those problems.This topic is designed to explain the No Surprises Act, including its history, the important problems the Act tries to solve, and how it attempts to solve those problems. Surprise balance billing has been a hot-button issue in state and federal politics for many years. The No Surprises Act radically changes the status quo for health plans, health care providers, and patients with respect to out-of-network care for emergency services, non-emergent services provided by out-of-network providers at in-network facilities, and air ambulance services. The Act goes into effect on January 1, 2022. Health care providers may be subject to steep fines if they impermissibly balance bill patients, and they may be unable to collect additional payment if they do not comply with specific requirements to submit claims to arbitration. Health plans are regulated in new ways that may impose additional financial liability for out-of-network claims. This material will provide you and understanding of the new requirements, challenges of implanting the Act, and strategies to adapt to the new way of paying for these out-of-network services.
AuthorsKristopher R. Alderman, FisherBroyles LLP
Introduction to the No Surprises Act
• What Are Balance Bills?
• What Are Surprise Balance Bills?
• What Are the Problems With Balance Bills?
• What Is the No Surprises Act and How Did It Come to Pass?
• When Does the No Surprises Act Go Into Effect?
Which Surprise Balance Bill Situations Are Affected by the No Surprises Act?
• Emergency Services
• Non-Emergent Services Provided by an Out-Of-Network Provider at an In-Network Facility
• Air Ambulance Services
• Everything Else Remains Unaffected
- Ground Ambulance
- Non-Emergent Out-Of-Network Services at Out-Of-Network Facilities
How Does the No Surprises Act Affect Surprise Balance Bill Situations?
• In These Situations, Providers Are Precluded From Balance Billing the Patient
• Notice and Consent Exception to the Balance Billing Prohibition
• Initial Health Plan Payments Are Not Regulated and the Current Greatest of Three Rule Will Cease to Exist
• Open Negotiation Period Between Provider and Plan
• If Negotiation Is Not Successful, Provider Can Submit the Dispute to a Baseball-Style Arbitration Process
Baseball-Style Arbitration Process
• Providers Must Act Promptly
• The Provider and Plan Are Required to Make a Final Offer
• The Arbitrator Must Select One of the Final Offers as the Required Payment Amount
• There Are Several Factors the Act Directs Arbitrators to Consider
• Arbitrators May Also Request, or Parties May Provide Additional Relevant Evidence as Long as It Does Not Refer to Certain Categories of Information That the Act Prohibits Arbitrators From Considering
• The Losing Party Pays the Arbitrator's Fee
• Batching of Claims
• Waiting Period
Implementation of the Arbitration Process
• Qualifying Payment Is a Central Factor
• Recent Hospital Pricing Transparency Rule Overlaps
• Who Will Serve as Arbitrators
• Other Uncertainty Left to Subsequent Regulations