What is the “No Surprise Bill”?
The No Surprises Act passed as part of the Consolidated Appropriations Act, is a regulation that aims to protect patients from the financial impact of surprise medical billing.
Surprise Medical Billing?
This happens when a patient receives care from an out-of-network provider in either an emergency, where the hospital might be out of network, or at an in-network facility where the patient wasn’t able to choose or select their provider. In cases like this there’s no contract in place between that provider and the plan. The provider usually sends the bill to the plan, the plan determines what they want to cover, and then historically that difference between the provider’s bill and what the plan pays is the due balance or surprise bill.
What changes does the regulation require?
Starting January 01 of 2022, a patient no longer is responsible for that balance. And they’re only responsible for the cost sharing amount that would have been applicable if the provider and the plan had a contract in place. The patients will also be responsible for the amount or estimate that the provider notifies before receiving care, in those cases which this process applies.
How will this regulation be applied?
Because the patient is no longer responsible for that balance, Congress set up a dispute resolution process to essentially ensure that that out-of-network physician or provider receives a fair payment. The law sets up what they called an Independent Dispute Resolution process, where each party submits their best offer to the arbiter and any evidence that’s permitted by the statute to support their offer. And then the arbiter picks one and that process is binding on both parties, and payments will be resolved under this process. For an arbiter to determine a fair payment, several factors should be considered by the arbiter. And those included things like the median in-network rate, the market dominance of both parties, the acuity of the patient and the complexity of the case, the teaching status of the hospital and so on.
Is there anything that practices can do proactively to address some of the challenges?
It’s important that physicians are aware of these changes and are incorporating these changes into the practices. They can follow the AMA’s developing and sharing educational resources and sign up for the AMA’s website ama-assn.org/advocacynews. It’s also important to encourage physicians to share their experiences about implementing these changes, in their practices, with their state and specialty medical societies.