The No Surprises Act that aims to protect healthcare consumers from going into sticker shock when they receive their medical bill is back in the news! It has raised a lot of dust and conflicting opinions. Here is all you need to know about this act and how it impacts providers and specific specialties.

A bit of backstory…

The No Surprises Act is a provision of the Consolidated Appropriations Act. It came into effect on 1st of January 2022. The NSA, governed by CMS ensures healthcare consumers are aware of their medical bills and provided with greater price transparency. It protects people covered under group or individual insurance when they receive medical care from out-of-network providers at in-network care settings. Healthcare consumers can also avail of the services of out-of-network air ambulance service providers without receiving a surprise medical bill.

The NSA, also establishes an independent dispute resolution process for financial disputes between insurers and providers. The newly instituted dispute resolution process can protect providers from disputes caused due to variances between medical bills and good faith estimates provided by physicians.

What exactly are surprise medical bills?

Before the No Surprises Act, people seeking care, even unknowingly, from out-of-network providers or hospitals had to incur high medical costs. The healthcare insurance company may refuse to cover the entire out-of -network cost. This can put patients in a perilous position. The NSA also prevents balance billing practices. It bans balance bills for specific additional services (such as anesthesiology) by out-of-network providers.

Provider specialties that are specifically impacted by the No Surprises Act:

• Neonatology
• Pathology
• Diagnostic Services
• Radiology
• Emergency Medicine
• Anesthesiology

How does the Advanced Explanation of Benefits (AEOB) work prior to receiving care?

The AEOB, for now, is created based on the good faith estimate provided by physicians to the patient’s health plan. The HHS will publish clear regulations on how the data in the AEOB should be calculated, in the coming months. It will outline how NSA’s provisions apply to Reference Based Pricing Plans.

The current concerns that have raised a storm in healthcare circles

The NSA, has received a bit of push-back from physicians. Some providers argue that the price cap mandated by the new law, does not reflect fair market value for medical care rendered. Some have filed lawsuits to fight against the new law.

In response, the Health and Human Services (HHS) department has stated it would write new regulations that would factor in other data. There is a lot of discussion around the law as it may lead to restricted access to care and insurers being extra careful about which providers they bring into their network. These unintentional consequences can be detrimental for people in under served communities.

How can SolvEdge help?

We can work closely with providers to track accounts in the IDR. We can also post contractual allowances/reimbursement details on behalf of providers. Our experts can shoulder some of the administrative burden faced by healthcare organizations.