Top 7 No Surprises Act Billing Rules for U.S. Private Practices
What Is the Federal No Surprise Act? The No Surprises Act is a piece of federal legislation that was implemented on January 1, 2022, with the purpose of protecting patients from unexpected medical costs, especially when they unintentionally receive care. From out-of-network providers. In essence, if your private practice offers services to patients with private health insurance, you are prohibited from charging patients more than their in-network cost-sharing amounts in specific surprise billing situations. Consequently, insurance companies are required to treat out-of-network claims in those instances as if they were in-network, and billing the patient for any remaining balance is not allowed. These billing regulations under the No Surprises Act apply to the majority of commercial health plans, including both employer-sponsored and individual plans, and encompass a variety of scenarios outlined below. (Patients enrolled in Medicare, Medicaid, TRICARE, or other federal programs already benefit from protections and are exempt from surprise billing.) What Are the Rules for Private Practices to Avoid Surprise Billing Penalties? According to the regulations of the No Surprises Act, healthcare providers and insurers must settle payment disputes independently, ensuring that patients are not involved in the process. The law established an Independent Dispute Resolution (IDR) mechanism for providers and health plans to negotiate and arbitrate fair compensation for out-of-network services when necessary. In the interim, patients are solely responsible for their typical in-network copayment, coinsurance, or deductible amounts under protected conditions. Failure to adhere to these requirements could result in federal fines of as much as $10,000 for each infraction for providers, highlighting the importance for small practices to understand the regulations and implement compliant billing practices. For a comprehensive guide on establishing compliant and efficient medical billing processes, please refer to our Fundamentals of Medical Billing Complete Guide. Below, we outline the essential elements of the No Surprises Act billing regulations, detailing when surprise billing protections are applicable, the nature of Good Faith Estimates (GFEs) and the new dispute resolution processes, the notifications required for patients, and the means to ensure compliance. These guidelines are designed to assist independent physician practices and clinics in adjusting to the federal No Surprise billing compliance and in preventing costly errors. Protections Against Surprise Billing in Emergencies A fundamental component of the No Surprises Act billing regulations is the elimination of surprise bills for emergency services. If a patient presents at an emergency department or an urgent care center (which is licensed for emergency care) and your practice or physicians deliver care that is out-of-network, you are prohibited from billing the patient beyond their usual in-network cost share for those emergency services. The health plan of the patient must provide coverage for emergency care as though it were in-network, irrespective of the inclusion of the hospital or physicians in the network, and the maximum amount that may be collected from the patient is their copayment or deductible. This regulation also applies to air ambulance transports (air ambulances are not permitted to charge patients more than in-network cost-sharing). However, ground ambulances are not included under the federal law and may still lead to balance bills (ground ambulance billing is being addressed separately, outside the scope of this Act). Emergency services encompass the initial treatment provided in the emergency room or urgent care, as well as specific post-stabilization care. Post-stabilization services, which refer to the continued care following an emergency until the patient is stable enough for transfer or discharge, are typically classified as emergency services under legal guidelines until the patient has stabilized and has given written consent for transfer or out-of-network care. Practically speaking, if one of your physicians is out-of-network and provides treatment to a patient in the emergency room (or is consulted for inpatient care immediately after an emergency), you are required to bill the patient’s insurance and accept the in-network rate (or negotiate with the insurer), instead of issuing a large balance bill to the patient. In emergencies, patients cannot be asked to forgo their surprise billing protections there is no allowance for notice and consent exceptions for emergency services. Out-of-Network Non-Emergency Services at In-Network Facilities The No Surprises Act billing regulations also safeguard patients who receive non-emergency care at in-network facilities when they are inadvertently treated by an out-of-network provider. This situation often results in surprise bills; for instance, a patient may schedule surgery at an in-network hospital, but certain providers (such as the anesthesiologist, radiologist, or even a consulting specialist). According to the new legislation, if your practice or physicians are out-of-network but operating within an in-network hospital or ambulatory surgery center, you generally cannot charge. The patient is shielded from the balance bill, akin to the emergency rule. How Payment Functions In essence, receiving care at an in-network facility activates surprise billing protections for the patient. The patient’s health plan will compensate you (the out-of-network provider) at a predetermined rate, and you are prohibited from pursuing the patient for any remaining balance. Instead, you should engage in negotiation or arbitration with the insurer if you believe the payment is inadequate (the IDR process is discussed below). This regulation applies to all out-of-network providers operating within an in-network facility, unless the provider adheres to a specific notice and consent protocol with the patient (and unless the service falls under certain exceptions that cannot be waived). Ancillary Providers: Waiver Prohibition The law categorizes specific specialties as “ancillary services” that are essential to a procedure and for which patients generally do not select the provider. These specialties encompass emergency medicine, anesthesiology, pathology, radiology, neonatology, and diagnostic services such as radiology or laboratory work, along with assistant surgeons, hospitalists, intensivists, and others who operate behind the scenes. If your practice offers any of these services at an in-network facility, you are never permitted to balance bill the patient, even with their consent. The patient is consistently safeguarded; you must accept the payment from the plan and the patient’s in-network contribution. Notice-and-Consent for Other Clinicians