No Surprises Act takes effect Jan. 1: 9 things for hospital leaders to know

December 29th, 2021 / Marissa Plescia

The No Surprises Act, which provides protections for consumers against surprise billing methods, will go into effect Jan. 1.

Here are nine things to know about the No Surprises Act, according to the Kaiser Family Foundation:

1. Protections from surprise billing will apply to most emergency services, including care provided in hospital emergency rooms, freestanding emergency departments and urgent care centers licensed to provide emergency care. Air ambulance transportation will be affected, but not ground ambulance.

2. The act says emergency services include post-stabilization services until a patient can safely move to an in-network hospital. The patient must receive a written notice about being transferred and must give consent.

3. The act also applies to nonemergency services by out-of-network providers at in-network hospitals.

4. Through the No Surprises Act, providers cannot bill patients more than the in-network sharing amount for services covered by the law. For each violation, there is a $10,000 penalty. Providers will have to find out the patient's insurance status and send the surprise out-out-of network bill to the health plan. Health plans then have to respond with the in-network cost sharing amount for that claim within 30 days.

5. Providers and health plans are responsible for determining if bills are protected under the act. They also must disclose to consumers their surprise billing protections.

6. If a patient gives prior written consent to waive their surprise billing rights, an exception is made to providers. But this consent must be voluntary, and providers cannot ask patients to waive their rights for emergency services or certain nonemergency services, such as diagnostics.

7. States are mostly responsible for enforcing the No Surprises Act against healthcare providers. However, they can enlist help from the federal government.

8. If consumers run into problems, they can appeal health plan denials, reach out to the enforcement entity, contact their state consumer assistance program or use the national consumer complaints system that will be established.

9. The amount paid for surprise out-of-network surprise bills will most likely be around the median rate paid to in-network providers in the area, but health plans and providers can negotiate between themselves. If they can't come to an agreement, they can request an independent dispute resolution process.