#PNN Surprise Bill

The federal No Surprises Act, which aims to eliminate unexpected out-of-network medical bills, took effect Jan. 1. Signed on December 27, 2020, the law is part of the Consolidated Appropriations Act COVID-19 relief bill. 

The Act, along with its implementing regulations, prohibits certain balance billing practices by out-of-network providers and mandates a set of disclosures with respect to health care services provided at hospitals and ambulatory surgical centers. The Act prohibits:

  • Surprise billing for emergency services. Emergency services, regardless of where they are provided, must be treated on an in-network basis without requirements for prior authorization.

  • Out-of-network charges for ancillary care (such as from an anesthesiologist or pathologist) at an in-network facility in all circumstances.

  • Out-of-network charges for surgeons and other non-ancillary professional services without advance notice to and consent of the patient.

  • Out-of-network cost-sharing for emergency services, and for non-emergency services in this context without the patient’s advance consent. Patient cost-sharing, such as co-insurance or a deductible, cannot be higher than if such services were provided by an in-network provider, and any coinsurance or deductible must be based on in-network provider rates.

The Act also contains notice requirements for health insurers and establishes an arbitration process for out-of-network services in this context, as well as mandates a plain-language consumer notice regarding:

  • the restrictions on balance billing for such services under the Act

  • any state law balance billing protections that may apply

  • how to contact relevant state and federal agencies if a patient believes that the provider has violated any of the restrictions

Click Here to read the full Act.

Listen to the Podcast Detailing the Acts Here.

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