No Surprises Act Implementation: What to Expect in 2022
Issue Brief
Balance bill refers to the difference between the full undiscounted charge and the amount the health plan recognizes as reasonable. Studies have found the average balance billing charge for surprise bills was over $1,200 for anesthesia, $2,600 for surgical assistants, and $750 for childbirth.
The No Surprises Act does not apply to Medicare or Medicaid, public programs that already strictly limit or prohibit balance billing by nonparticipating providers.
“Interim final” means the regulations take effect, but public comment is requested and future amendments are possible.
In addition to surprise billing protections, the No Surprises Act sets other standards for private health plan coverage of emergency care. For example, health plans will be prohibited from denying claims for emergency care simply because the patient turned out to not be experiencing a medical emergency (for example, if a patient sought emergency care for chest pain that turned out to be caused by indigestion instead of a heart attack).
The law establishes an advisory committee to make recommendations on whether and how Congress might apply federal surprise medical bill protections for ground ambulance services. Meanwhile ten states do provide surprise medical bill protections for ground ambulance services.
The consent form is shown at Appendix 2. The form is not required to include information stating that the patient is medically able to be transferred nor does it require a signature by the medical professional certifying the patient’s condition.
In states with an all-payer rate setting system or other state law determining payment rates for surprise medical bills, patient cost sharing could be based on the state-determined amount.
For example, as part of implementation of its surprise bill law, the state of Washington requires insurers to include a standardized transaction code on all claims subject to that state’s balance billing law in order to notify providers that state law applies to the claim; Washington also requires a standard code must be included on EOBs to notify consumers that a claim is subject to state law balance billing protections.
In addition to the statutorily required numbers of health plan audits, DOL and HHS can undertake any number of additional investigations or audits in response to complaints.
CMS staff comments offered during meeting with consumer advocates on NSA implementation, November 30, 2021.
In states with an all-payer rate setting system or other state law determining payment rates for surprise medical bills, the QPA could be the state-determined amount.
HHS is currently taking applications from entities to be certified IDRs and expects to certify 50 entities. States with their own surprise medical bill laws can apply a different state-designed IDR process to resolve payment disputes involving state-regulated plans. Currently, several states also allow plans they don’t regulate (self-insured employer plans) to elect to use the state IDR process if they prefer.
The No Surprises Act also establishes a payment dispute resolution process for providers and uninsured (or self-pay) patients. Under the law, uninsured patients have the right to request a good faith estimate of the cost of care they seek; if the actual amount charge is significantly in excess of the estimated amount (by at least $400), the patient can ask an IDR entity selected by HHS – the selected dispute resolution, or SDR entity – to review the charges and determine whether they should be reduced. In the regulations HHS estimates about 3.5 million uninsured or self-pay individuals will receive good faith cost estimates annually, and the SDR will be asked to review 26,659 cases annually.
In addition each party pays a $50 administrative fee to use the IDR process.