December 16, 2021
The federal No Surprises
Act takes effect January 1, 2022, bringing new balance billing requirements for
health plans and providers. Here’s a brief overview to help you understand the
balance billing provisions that may impact you in 2022.
Emergency Care
Providers are prohibited
from balance billing patients for out-of-network emergency services. In some
situations, this may include the following types of services: stabilization and
post-stabilization; patient transfer; ancillary services; and out-patient observation
or inpatient or out-patient stays relating to the emergency services.
Informed Consent
The new federal rules allow
that a non-contracted provider may balance bill after the patient is
stabilized, if: the patient can travel using non-medical transportation or
non-emergency medical transportation; the provider gave notice that the
additional items/services are non-contracted including the cost; and they’ve
received acknowledgement of the notice from the patient, who’s been determined
capable of consent.
This provision will not
apply in WA for fully insured health plans and those self-funded plans that
opted into the state balance billing protections. This is because the federal
law doesn’t pre-empt state balance billing laws except where the federal protections
are broader or more favorable to consumers.
Ancillary Services
For ancillary services a
balance bill is never allowed (emergency or non-emergency) under the No
Surprises Act. However, there is an exception for certain non-ancillary
services at an in-network facility where the provider informs the patient in
advance that they are non-contracted and gives them an estimate of the charges.
Air Ambulance
The No Surprises Act covers
air ambulance services and prohibits air ambulance providers from balance
billing if they are non-contracted. The law also requires health plans to cover
non-contracted air ambulance services for any services that would be covered if
the air ambulance provider was in-network, and to apply in-network cost-sharing
in the same way as other emergency services. Air ambulance providers are also
included in the independent dispute resolution (IDR) process, if needed.
Learn More
Additional provisions
related to balance billing have been delayed by the government but should be
coming later in 2022. We’ll be communicating more about the No Surprises Act in
future issues of Provider News. Here are some resources are available: