Surprise! Are you ready for the No Surprises Act?

Rebecca Welker, Shameka Smith, and Rich Costello
| 3/7/2022
Surprise! Are you ready for the No Surprises Act?

The No Surprises Act significantly changes how providers and commercial health insurance plans engage with patients and each other. The regulation is complex and continues to evolve based on public comment and pending lawsuits.

Patient protections

The No Surprises Act, effective Jan. 1, 2022, establishes new patient protections against surprise medical bills (that is, unexpected balance billing, in which consumers are billed for the difference between what an out-of-network (OON) provider bills and what the patient’s health plan covers). Surprise bills arise when insured patients receive care from OON hospitals, doctors, or other providers they did not choose. Examples of patient protections included in the act are as follows:

  • Surprise billing for most emergency services is banned. Emergency services, regardless of where they are provided, must be treated and billed on an in-network basis without requirements for prior authorization, unless the patient signs a notice of consent.
  • OON charges for ancillary services (such as anesthesiology or radiology) at an in-network facility are banned.
  • Air ambulance services from OON providers are banned.
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What healthcare facilities need to know

  • Penalties for violation: For services covered by the No Surprises Act, providers are prohibited from billing patients more than the applicable in-network cost-sharing amount; a penalty of up to $10,000 for each violation may apply. This is on top of the reputational risk hospitals face in such situations.
  • Public disclosure requirements: A disclosure explaining a patient’s right to receive an estimate of their medical costs, or a link to the disclosure, must appear on a searchable homepage of the provider’s or facility’s public website, be posted at the facility, be available in the 15 most common languages, and be provided to patients receiving services covered under the No Surprises Act.
  • Advance estimates for nonemergent care (excluding certain ancillary services):
    • Uninsured/self-pay patients must receive a good faith estimate in advance and may dispute any bill that is at least $400 over the estimate.
    • Insured patients receiving care from an OON provider or facility must receive a surprise billing protection form at least 72 hours in advance of care. Additionally, unless a patient consents in advance, that patient cannot be billed more than the in-network cost-sharing amount for services covered by the No Surprises Act.
  • Independent dispute resolution (IDR) process: Providers and insurers are encouraged to negotiate settlement of claims for OON services within 30 business days. Otherwise, they must initiate the IDR process and submit their case to an appointed IDR entity for settlement. On Dec. 9, 2021, the American Medical Association and the American Hospital Association challenged the IDR process, and the lawsuits are in U.S. District Court as of the date of this publication.

What facilities can do now

Healthcare providers should review their procedures to determine whether they are in compliance with the No Surprises Act. In addition, they might consider working with third-party revenue cycle, internal audit, and compliance professionals who are well versed in the No Surprises Act requirements and can provide implementation checklists, compliance assessment reviews, and educational services for board members and staff.

Learn more

Learn more about how Crowe can provide industry-specific financial, regulatory, and technology expertise for your healthcare organization.
Rebecca M. Welker
Managing Director, Healthcare Consulting
Rich Costello
Healthcare Consulting
Shameka Smith
Shameka Smith
Principal, Healthcare Consulting