“No Surprise Act” focused on eliminating Balanced Billing

    An Interim Final Rule was recently issued by the Department of Health and Human Services, the Department of Labor, the Department of the Treasury, and the Office of Management and Budget implementing key provisions of the No Surprise Act, which was passed late last year to stop surprise balanced billing as part of the Consolidated Appropriations Act of 2021.

    Balanced billing is the difference between a healthcare provider’s charge and the amount of coverage provided by an insurance company. Participants seeking care often find themselves with a surprise balanced bill for services that they thought were fully covered under their insurance policy. This commonly occurs when participants receive emergency care at out-of-network facilities, or when they receive elective nonemergency care through an in-network facility or provider but are inadvertently treated by an out-of-network health care member.

    The No Surprise Act is designed to provide greater consumer protection by eliminating highly expensive out of pocket costs associated with balanced billing and states that:

    • Emergency services must be covered without prior authorization and regardless of where they are provided. They must be treated on an in-network basis.
    • Non-emergency services at in-network facilities must be covered in-network and cannot be charged as an out-of-network service. This is intended to prevent situations where participants are treated at an in-network facility and provider but end up being charged out of network fees for such services as anesthesiology or lab work.
    • Higher out-of-network cost-sharing fees must be based on in-network provider rates. Patient cost-sharing, such as co-insurance or deductibles, cannot be higher than if such services were provided by an in-network doctor.
    • Advance notice must be provided for other out-of-network charges. Health care providers and facilities must provide patients with a plain-language consumer notice explaining that patient consent is required to receive care on an out-of-network basis before that provider can bill at the higher out-of-network rate.

    The majority of the requirements under this act will become effective beginning January 2022. The July 1, 2021, interim final rule is the first of several expected this year for the remaining parts of the legislation. For states that already have surprise billing laws on the books, their laws will not be pre-empted unless they are less stringent, stricter set of regulations take precedence when federal and state regulations conflict.

    For link below for complete versions of the acts:

    No Surprise Act

    Consolidated Appropriations Act, 2021