The No Surprises Act was passed by Congress last December. It’s set to go into effect in early 2022. That’s great news because the bill is aimed at stopping certain types of surprise medical bills. Like the bill you get from an out-of-network (OON) doctor in an in-network facility. Or an emergency room bill from an OON hospital you didn’t choose. Learn more about surprise medical bills with my post 5 Insurance Words You Need to Avoid Surprise Bills.
So the No Surprises Act will help you unexpected medical costs. But as you’ll hear me say over and over, the devil is in the details. In this case, the potential devil is the surprises in the No Surprises Act. I’ll take you through the devilish details of how the bill will protect you, exceptions to the rules, and what still has to be worked out.
What the No Surprises Act Does
Let’s start with how the bill will protect you. In certain cases, you will only have to pay in-network costs even if the services are from an OON provider. You cannot be billed for the balance (known as a “balance bill.”) This protection applies to emergency services or for providers or services from OON providers in an in-network facility. Surprise — The bill does not cover ground ambulance charges. In other words, you can still be billed OON fees for ground ambulance services.
Who Pays? Not You!
Under the No Surprises Act, providers cannot bill you or hold you liable for the balance bill. How does it get paid? The insurance company and provider can negotiate a settlement between themselves. Or they can go to Independent Dispute Resolution (IDR), which is like arbitration.
In IDR both parties present what they think is a fair settlement amount. The arbitrator will pick one of their figures. If the provider is owed money, the insurance company pays the bill. The losing party pays for the IDR. You pay for none of it.
There are many potential surprises with IDR because we don’t know how it will work out over time. How often will it be used? Will insurance companies have to pay a lot of high-dollar balance bills? Will the cost of care go up as a result of IDR negotiations? We probably won’t know until there is at least one year of IDR cases to review.
Exceptions to the No Surprises Act
Of course there are exceptions! In order for an OON provider to balance bill you, at least 72 hours before you receive services they must give you the following information in writing:
- Tell you the provider is OON
- Explain that you may get care elsewhere (such as with an in-network provider)
- Provide a good faith estimate of anticipated charges
You must give your consent in writing. Very ugly surprise — their written notification might be buried in a stack of other forms you’re signing. You may not even know what you’re signing. Especially if you’re not feeling well or anxious about an upcoming procedure.
What should you do? Take an advocate, trusted friend, or family member with you when you’re signing documents. They can help you understand what you’re being asked to sign.
What’s on the Horizon
Many important devilish details need to be worked out before early 2022. Among the big ones are exactly how IDR will work and how rules will be enforced. When the bill was being created, there was intense lobbying by providers, insurance companies, and private investors who bought into lucrative emergency physician groups. You can bet these same groups will lobby the Biden Administration for details that favor their interests.
There could be unintended long-term cost surprises for health care consumers. For example, if the insurance companies have to start paying the balance bills, they could pass those increased costs to you through higher premiums.
For now, we’ll have to wait to see what choices are made by the government officials creating the No Surprises Act final rules. Then in 2022, let’s see if this bill actually brings the intended protection to health care consumers. Or will the unintended surprises in the No Surprises Act reduce your protection? I will update you as the facts unfold!