Medical Providers: Don’t Be Caught By Surprise!

By Associate Attorney Danielle Nodar

The No Surprise Act, a new law establishing protections for consumers against surprise medical billing, became effective on January 1, 2022. This law protects individuals covered by insurance from receiving surprise medical bills when receiving certain kinds of medical services, particularly emergency services, at an out-of-network facility or from out-of-network providers working at an in-network facility. Before this law became effective, an insured patient receiving care from an out-of-network provider or at an out-of-network facility may have been responsible for the balance of the bill not covered by their insurance, which could result in a patient being responsible for hundreds or thousands of dollars in “balance” or “surprise” bills. This applied even if a patient went to an in-network facility but unknowingly received care from an out-of-network provider, like an anesthesiologist or radiologist.

The No Surprise Act protects consumers from these surprise medical bills by banning surprise bills for most emergency services, even if they were received at an out-of-network facility, banning surprise billing for certain non-emergency services provided by out-of-network providers in an in-network facility, and requiring insurance to cover out-of-network claims and apply in-network rates. The law’s main aim is to protect insured consumers who may unknowingly receive out-of-network treatment.

The No Surprise Act also provides consumer protections to uninsured patients or those who choose to pay for their care out of pocket by requiring most providers to provide a good faith estimate of how much your care will cost before you receive treatment. Also, if there is a dispute over the amount payable, patients no longer serve as the middleman, as the Act establishes a negotiation and arbitration procedure between the insurance carrier and out-of-network provider.

The No Surprise Act does not apply if the patient gives prior written consent to waive their rights under the Act and be billed more for out-of-network providers. This waiver exception does not apply in an emergency situation. Consent must be voluntarily given, and the notice must clearly explain the rights the patient is waiving. Otherwise, a provider can refuse care if consent is denied. 

As this law is still new, there are still many aspects that have not been clarified, such as how the law is enforced and applied to different providers. For example, some medical communities have concerns with providing a good faith estimate prior to treatment as it may be difficult due to a lack of diagnosis or may serve as a deterrent to care for certain patients, such as those seeking mental health treatment. However, medical providers impacted by the law still have a duty to comply with its requirements, particularly with regard to notices of a patient’s rights under the law, waivers and consent to balance billing, and good faith estimates. If you think your practice may be impacted by this law, please feel free to contact Jesson & Rains.