Effective January 1, 2022, the No Surprises Act went into effect with regard to emergency care and balance billing by non-network providers. An undoubtedly complex piece of legislation, GMS' Vice President of Benefits Beth Kohmann experts share some of the key takeaways below.
With this new ruling, if a group health plan covers any type of emergency care, then emergency care treatment rendered through the stabilization of the patient must be covered by the group health plan – even if services are rendered by a non-network provider. The group health plan must cover these services at the in-network level of benefits. The group health plan will consider these charges at a qualified payment amount level and negotiate (if the qualifying payment amount is appealed) with the non-network provider until an acceptable payment amount is reached. The patient cannot be balanced billed for the difference between the billed charge and the agreed-upon payment amount.
This applies to such providers as facilities, emergency room physicians, anesthesiologists, and air ambulances. Ground ambulance providers are not subject to the above ruling and would be permitted to balance bill a patient for the difference between the total charge and the qualifying payment amount.
The same applies to non-emergency care where the patient would have no choice of provider. For example, if a patient is having surgery at a network facility with a network surgeon and the anesthesiologist or outside laboratory are non-network providers, the group health plan must pay these providers at the in-network level of benefits and at a qualified payment amount (or a negotiated rate if the qualified payment amount is appealed). As above, the patient cannot be balance-billed for the difference between the billed charges and the agreed-upon payment amount.
If the patient chooses treatment from a provider that is not in-network for services, for example, a surgical center or surgeon, that provider must inform the patient of the estimated fee, prior to rendering treatment, for their services and explain that they could be balance billed for any non-allowed amounts. This must be in writing and the patient will need to sign a document stating they acknowledge and understand that they could be balance billed.
This ruling will apply to any claims incurred after January 1, 2022. To stay in the know with the latest legislation and compliance, be sure to subscribe to our email list.