Did you know that the US Congress passed the largest spending bill in its history almost 1 year ago?
On December 27, 2020, then-President Donald J. Trump signed into law a 5,593 pages-long bipartisan legislation entitled “The Consolidated Appropriations Act, 2021” aimed at distributing COVID-19 stimulus relief in the Fiscal Year 2021. Apart from over a hundred diverse aspects mentioned in this revolutionary legislation, a significant portion of the Act focuses on maintaining the good & stable financial well-being of millions of patients nationwide. Specifically, this legislation includes another Act within itself – the No Surprises Act that prohibits a so-called “surprise” patient billing in certain situations.
A surprise bill is an unexpected medical bill received by a patient from a healthcare provider who has previously rendered a service to this patient. This can occur when a person with health insurance unknowingly receives medical treatment from a provider who is not in their health plan's network, in both emergency and non-emergency situations. When a patient travels to an in-network hospital for emergency care and receives care from non-participating providers at that facility, the future medical bill is likely to come unexpectedly. When an unconscious patient, for example, receives treatment at an in-network facility or from an in-network provider, they sometimes may be unaware that a provider engaged in their care (such as an anesthesiologist or radiologist) is out-of-network with the plan.
On September 30, 2021, the government issued an interim final rule with a comment period, entitled “Requirements Related to Surprise Billing; Part II” under the No Surprises Act. This rule establishes new protections from surprise billing and excessive cost-sharing for consumers receiving health care items/services. It implements additional protections against surprise medical bills, such as an independent dispute resolution process, good faith estimates for uninsured (or self-pay) individuals, the patient-provider dispute resolution process, and expanded rights to external review. The final rule determines the following aspects:
• Balance billing is prohibited for emergency services.
• Patient cost-sharing for emergency services and certain non-emergency services provided at an in-network facility cannot be higher than if such services were provided by an in-network provider, and any cost-sharing obligation must be based on in-network provider rates.
• Out-of-network (OON) charges for items or services provided by an OON provider at an in-network facility are prohibited, unless certain notice and consent are given by a patient.
To sum up, providers are no longer allowed to perform balance billing for emergency services. At the same time, it is now prohibited to bill out-of-network charges for services performed at an in-network facility without a patient’s consent. Finally, uninsured individuals must not receive a bill for an amount that exceeds a good faith estimate. These regulations are settled & enforced by several dispute resolution processes if certain conditions are met.