To help ensure there are ‘no surprises’ when the No Surprise Act goes into effect, we’re taking a closer look at the latest rule, what it means and some potential consequences.
What
The “Requirements Related to Surprise Billing; Part II” rule builds on the previous legislature from earlier this year to continue the implementation of the No Surprises Act. Issued on September 30, 2021, it outlines a collection of additional consumer protections against surprise billing, including:
A process that removes consumers from the middle of payment disputes between providers and health plans
Requirements for health care cost estimates for uninsured individuals
A payment dispute resolution process for uninsured individuals
Expanded rights to external review (what individuals with job-based or individual health plans can use to dispute when certain claims are denied payment)
The rule also details how providers, facilities and plans or issuers can negotiate payment for out-of-network bills and access the federal arbitration process when a payment can’t be agreed upon between organizations. More information on this process can be found here.
Who
Overall, these protections against surprise billing apply to consumers who:
Get their coverage through their employer (including federal, state and local government employer)
Get their coverage through a multi-employer plan
Get their coverage through the federal Marketplace and state-based Marketplaces
Purchase coverage directly through a health insurance plan
If consumers are uninsured or self-pay for care, this rule ensures they know how much their health care will cost before they get it and have a way to challenge a bill if it’s much larger than expected.
In addition to protecting consumers, the balance billing provisions in the No Surprise Act have the potential to decrease health care spending. The Congressional Budget Office has projected the No Surprise Act will reduce private health plan premiums by 0.5% – 1% on average.
Why
Surprise bills can be expensive for patients, their employers and the entire health care system.
They can also take many forms. An out-of-network provider may bill the individual for the difference between the charge and the amount paid by their plan or insurance. A person with health insurance could unknowingly get medical care from and out-of-network provider/facility. Plus, surprise billing can happen in both emergency and non-emergency settings.
In an emergency, an individual usually receives care at the nearest emergency department. Even if they go to an in-network hospital, they may receive care from an out-of-network provider.
In a non-emergency, individuals may select an in-network facility and provider but not know that someone involved in their case like an anesthesiologist or radiologist is an out-of-network provider.
Surprise billing has also been used as leverage by providers to get higher in-network payments, which result in higher premiums, higher cost-sharing for consumers, and increased health care spending overall.
When
Both the “Requirements Related to Surprise Billing; Part I” and “Requirements Related to Surprise Billing; Part II” rules will go into effect on January 1, 2022.
Considerations and Potential Consequences
It’s likely the law will prompt more providers to join an insurer network.
There’s a potential for insurers to drive down payment to the point that it is no longer feasible for providers to take their insurance.
Some have observed the potential for shifting costs and leading to higher insurance premiums.
Others believe it will help decrease costs.
Many hospitals and physician groups are in opposition warning it could cause things like imaging cuts and reduced patient access to care.
While Simpara expects many more rule changes to have effect, likely with delays, this long-awaited bill is a step in the right direction!
