What Is the No Surprises Act? Facility Guide and FAQ

With rising care costs, it’s not uncommon for patients in the U.S. to experience unexpected medical debt after being treated for illness or injury. Getting accurate breakdowns of costs prior to receiving care is often difficult for patients, limiting their ability to pinpoint affordable options. The federal No Surprises Act was enacted as a way to improve accessibility and transparency in healthcare and address some of these financial burdens.

But, what is the No Surprises Act and how does it impact facilities? In this guide, we’ll go over key provisions of this pivotal piece of legislation and answer the most frequently asked questions about how it affects your patients and practice.

What Is the No Surprises Act? Summary and Overview

The No Surprises Act outlines a set of provisions designed to prevent patients from getting unexpected medical bills while reducing gaps in insurance coverage. It was signed into law in December of 2020 as part of the Consolidated Appropriations Act, and went into effect in 2022.

The overarching purpose of this act is to help prevent practices that lead to surprise billing, which is when patients unknowingly obtain and are charged for care services that are not covered by their insurance. In addition to these protections, there are also provisions that improve the transparency of care costs and help resolve discrepancies in medical billing.

Frequently Asked Questions

Now that we’ve broadly answered the question, What is the No Surprises Billing Act? you may be wondering how these provisions apply to your patients and facility. We’ll provide answers to some of the most frequently asked questions to further explain the intricacies of the No Surprises Act text.

What is included in the No Surprises Act?

The No Surprises Act helps prevent unexpected bills and enables patients to get a better understanding of their healthcare costs. More generally, this act establishes:

• Protections against surprise medical bills. Patients are protected from being charged for out-of-network emergency care and certain scheduled services without consent.

• Rights to receive good faith estimates. Patients who are uninsured or choose not to use insurance have the right to request an estimate of their expected bill. This applies to services scheduled at least three days in advance.

• Processes for determining cost-sharing. Insurers and providers must follow established methods for determining the costs that a patient is responsible for in situations falling under the No Surprises Act.

• Guidelines for dispute resolution. These provisions outline a standardized process for how payment disputes should be resolved between providers and health plans. It also protects patients from becoming involved in these disputes.

What is an example of surprise billing?

Surprise billing can often occur when patients go to an in-network facility but receive care from an out-of-network provider. For example, a patient might go to an ambulatory surgery center listed as “in-network” under their insurance plan, but then receive care from an anesthesiologist who, individually, does not participate in the health plan. This would lead to unexpected, out-of-network charges from services by this provider.

Who does the No Surprises Act apply to?

When it comes to medical billing, the No Surprises Act protections apply to patients under individual and group health plans who receive:

• Emergency services from out-of-network hospitals or independent emergency departments.
• Non-emergency services from out-of-network providers delivered as part of a patient’s visit to certain in-network facilities.
• Services from out-of-network air ambulances.

While patients may still be responsible for some portion of their bill in these cases, the out-of-network costs can’t be greater than in-network costs under the No Surprises Act.

When it comes to providing good faith estimates, the following types of facilities must comply with the Act’s requirements:

• Hospitals and outpatient departments
• Independent emergency departments
• Critical access hospitals
• Ambulatory surgical centers
• Rural health clinics
• Federally Qualified Health Centers (FQHCs)
• Laboratory and imaging centers

What are some exceptions to the No Surprises Act?

The No Surprises Act does not apply to patients with government-funded health plans. These plans include Medicare (and Medicare Advantage), Medicaid (including Medicaid managed plans), Indian Health Service, TRICARE, and Veterans Affairs Health Care.

Who enforces the No Surprises Act?

Regarding enforcement, state governments have the most authority over health insurance companies, facilities, and healthcare providers. But, if a state fails to enforce any of these provisions, the Centers for Medicare and Medicaid Services (CMS) will step in.

It’s also important to note that the No Surprises Act is meant to supplement existing state laws. This act is not intended to override or replace state laws that already address overlapping issues related to surprise billing.

How can facilities maintain compliance with the No Surprises Act?

Beyond knowing how to answer, What is the No Surprises Act? facilities should take ongoing measures to maintain compliance. Here are three tips and links to resources that can help you enforce these provisions at your organization.

• Train and educate your providers. Keep your providers and staff in the loop about how to properly bill for situations falling under this act and calculate good faith estimates. You can find a number of helpful toolkits from the American Medical Association and the American Psychiatric Association.

• Stay up-to-date on relevant state laws. Learn how your state’s billing laws complement or enhance the No Surprises Act to adhere to appropriate guidelines. You can use the Commonwealth Fund’s database to find billing laws that apply in your state.

• Incorporate guidelines into your billing process. Stay up-to-date on guidelines surrounding the No Surprises Act through CMS and incorporate them into your regular billing practices. This will minimize the risk of noncompliance, errors, and disputes.

Need Additional Help Maintaining Regulatory Compliance?

Now that you can answer the question, What is the No Surprises Act? you may be seeking practical ways to keep up with other relevant laws. Need help staying informed? Get dozens of useful tips on healthcare compliance and management delivered straight to your inbox.

Legal Disclaimer: This article contains general legal information, but it is not intended to constitute professional legal advice for any particular situation and should not be relied on as professional legal advice. Any references to the law may not be current, as laws regularly change through updates in legislation, regulation, and case law at the federal and state level. Nothing in this article should be interpreted as creating an attorney-client relationship. If you have legal questions, you should seek the advice of an attorney licensed to practice in your jurisdiction.