Beginning January 1, 2022, the new protections against surprise medical bills to The No Surprise Act (NSA) became effective. These new rules have been implemented to protect consumers from excessive out-of-pocket costs for emergency, post-emergency stabilization, and non-emergency services rendered from out-of-network providers at an in-network facility.
Previously, if a patient had health insurance and received care from an out-of-network provider within an in-network facility, knowingly or inadvertently, their health plan may not have covered the entire cost, leaving a balanced owed to the patient. This is what is known as a surprise medical bill.
If a patient has health coverage through an employer, the Health Insurance Marketplace, or an individual health insurance plan, the new rules will:
If a patient does not have health insurance or chooses to pay their medical expenses without using health insurance (self-pay), these new rules require that the health care provider or facility rendering services provide the patient with a “good faith” estimate of how much the charges will be for an item or service. In addition, providers and facilities must:
If a patient is billed over $400 more than the good-faith estimate provided when the service was scheduled, they may utilize a new patient-provider dispute resolution process to determine a payment amount. This process is done by a third-party arbitrator. A patient may use this process only if they meet the following requirements:
Some providers can ask the patient to waive their rights voluntarily. This may be done by prior written consent from the patient but is never allowed for emergency services or certain other non-emergency services covered by the NSA. Notice and Consent Waiver is not permitted for the following:
The regulation defines “facilities” to include hospitals, hospital outpatient departments, and ambulatory surgery centers. Consumers currently do not have federal protections against surprise bills for nonemergency services provided in other facilities such as clinics, nursing homes, or urgent care centers. Patients seeking services or care at such facilities may want to inquire about whether providers bill independently and/ or are in network.
Pure Healthcare Compliance Department
4179 S Riverboat Road, Suite 203
Taylorsville UT 84123