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Don’t Be Surprised By The Federal ‘No Surprises Act’

Thursday, December 16, 2021

Implementation of the No Surprises Act, which was passed by Congress as part of the Consolidated Appropriates Act of 2022, begins on January 1, 2022.  This federal regulation aims to provide patients with new protections against surprise medical bills from out-of-network providers and facilities by prohibiting certain balance billing and creating more transparency around the cost of services.  It also establishes an independent dispute resolution process for providers and health plans to use to resolve out-of-network care payment disputes. 

Below are key provisions starting January 1, 2022, for which physicians and other providers need to be aware.  The Michigan State Medical Society (MSMS) Legal Counsel is finalizing a more detailed document on the No Surprises Act, including how it aligns with Michigan’s statute prohibiting surprise billing.

Patient Balance Billing Protections – Under the federal law, these protections apply to emergency services, air ambulance transportation, post-emergency stabilization services, and non-emergency services provided by out-of-network providers at in-network facilities.  Physicians, hospitals, and other covered providers who furnish care protected by the No Surprises Act are no longer permitted to bill patients for more than the in-network cost sharing amount.  Instead of billing patients directly, out-of-network providers will submit the bill directly to the patient’s health plan. Health plans are required to notify providers of the applicable in-network cost sharing amount, make an initial payment, and send the patient an explanation of benefits indicating what the plan has paid and what the patient still owes the out-of-network provider. 

The No Surprise Act permits out-of-network providers at in-network facilities to balance bill patients for certain services if notice and consent requirements are met within specified time periods.

Good Faith Estimate – Regardless of setting, all physicians, facilities, and other health care providers must provide uninsured and self-pay patients with a good faith estimate (GFE) of the expected charges, expected service, and diagnostic codes of scheduled services.  In order to comply with this requirement, patients scheduling a service will need to be asked if they are covered by a health plan and, if so, whether they intend to have their claim(s) for the service submitted to the plan.  The GFE must be provided upon request or upon scheduling care at least one or three business days in advance (depending on when the service is scheduled) and be written in clear and understandable language. 

Disclosures – Physicians, facilities, and other health care providers are required to disclose patient protections against balance billing.  This disclosure must include how to report violations and be posted in a prominent location at the practice or facility, posted on a public website (if applicable), and provided to the patient.

Provider Directories – In order to ensure up-to-date information is available for patients, physicians, facilities, and other health care providers are required to provide health plans with directory information at specified time periods.

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