You are probably thinking: “But, I love surprises!” But, the type of surprise that the No Surprises Act refers to is no fun.
In the United States, when a patient sees a clinician who is not in the network of clinicians who have a contract with their medical insurance, that “out-of-network” clinician is allowed to bill the patient for the difference (“balance”) between the out-of-network clinician’s fees and the amount that the patient’s health insurance pays. This is known as “balance billing”. (Of course, implied in this is the fact that out-of-network clinicians charge more than the contracted fee that in-network clinicians accept.)
If the patient didn’t know that there would be a balance bill to pay out of pocket, that unexpected bill is what is being referred to as a “surprise” medical bill. All of the above also applies if a patient gets medical care at an out-of-network treatment facility. Apparently, such “surprise” bills are quite common (source).
The Consolidated Appropriations Act of 2021 includes provisions to help protect patients from surprise bills, including the No Surprises Act. The Act went into effect on January 1, 2022. On this page, we’ll explain, in as simple a manner as possible, what the Consolidated Appropriations Act of 2021 either prohibits or requires of us. Some of the provisions of the Act don’t apply to some mental health clinicians, for example, those who only see patients who have a health insurance plan they contract with.
What is now banned
1. The Act bans surprise bills for emergency medical care, even if that care is received out-of-network and without prior authorization.
2. For non-emergency care, even if patients go to an in-network facility, some clinicians at the facility (for example, the anesthetist or radiologist) may be out-of-network. In the past, patients received either out-of-network charges or balance bills for these supplemental services. Well, not any more. Such charges and balance bills have been banned.
Transparency: For which patients
The requirements discussed in the rest of this article, apply to:
– Out-of-network care, whether it is entirely self-pay or the health insurance pays part of the cost.
– Uninsured patients.
Not only future patients but patients who are currently under our care are also covered by this law.
Patients who are not affected
If a patient has health insurance and is seeing an in-network clinician, the existing rules apply and nothing has changed.
Also, even before the Consolidated Appropriations Act of 2021 went into effect, patients have already been protected against surprise medical billing if they had medical coverage through Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care, or TRICARE.
What measures are now required for transparency
1. The Consolidated Appropriations Act of 2021 requires that clinicians and facilities give patients an easy-to-understand notice explaining that getting out-of-network with them could be more expensive than getting in-network care. So that there won’t be any surprises. The notice must also explain what options the patient has for avoiding a balance bill. I assume that the alternative would usually be to go to an in-network clinician or facility, right? Note: The patient is not required to sign this notice.
2. Sometimes, the patient pays out-of-pocket (called “self-pay”) due to either not having health insurance or choosing deliberately to not use their health insurance and get care out-of-network. For these self-pay situations, the “transparency” part of the Consolidated Appropriations Act of 2021 requires that, before patients receive such self-pay medical care, they must be given a “good faith” estimate of how much this care will cost them. The good faith estimate must include a list of all items and services that will be associated with the patient’s care.
What does the good faith estimate need to include?
For a sample Good Faith Estimate, please click on THIS LINK.
The good faith estimate should include (source):
1. Patient’s name and date of birth
2. Description of the main item or service that will be provided
3. Itemized list of the items or services that are “reasonably expected” to be furnished
4. For each item or service: the diagnosis code, the expected service codes, and the expected charges
5. If applicable, the date for which the service has been scheduled
6. The name, National Provider Identifier, and Tax Identification Number (TIN) of the clinician(s) and/or facilities
7. The location (including, of course, the state) of the office and/or facility
8. A list of items or services that are expected to be needed before or after the primary service and to require separate scheduling.
Since all the above information is, obviously, not enough, we also need to include the following disclaimers:
– That more services may be recommended later that must be scheduled separately and are not included in this good faith estimate.
– That the actual items, services, or charges may differ from the good faith estimate
– That, if the actual billed charges substantially exceed the expected charges included in the good faith estimate, the patient has the right to initiate a dispute resolution process. Instructions for where the patient can find information about how to do this must be included. A statement that initiating a dispute resolution process will not adversely affect the quality of health care services provided to the patient.
– That the good faith estimate is not a contract and there is no requirement that the patient must get the items or services from any of the clinicians/ facilities listed in the good faith estimate.
Timing of the good faith estimate
The good faith estimate must be provided to the patient sufficiently in advance of the appointment, according to the following requirements (source):
1. If the patient makes an appointment for between 3 to 9 business days in the future, then the good faith estimate must be given to the patient within one business day after the appointment was made.
2. If the patient makes an appointment for 10 business days or more in the future, then the good faith estimate must be given within 3 business days after the appointment was made.
3. If the patient (self-pay or insured) asks for a good faith estimate without making an appointment, then the good faith estimate must be given within 3 business days after that request was made.
Estimate versus reality
Since the good faith estimate is, as the name indicates, only an estimate, the actual care the patient ends up needing and/or the actual charges can differ from the services and charges that were spelled out in the good faith estimate. Thankfully, that’s not prohibited.
But, if the amount actually charged exceeds the good faith estimate by $400 or more, the patient can challenge the bill through a dispute process that has been specified in the new law.
Payment disagreements or disputes
If the need arises (hopefully, not!), for information about how disagreements or disputes are to be resolved, we can see the following articles from the Centers for Medicare and Medicaid Services:
Resolving billing disagreements
Medical bill disagreements if you’re uninsured
– See the articles linked to under References below
– No Surprises Help Desk: 1-800-985-3059
Disclaimer: The information on this page is current as of January 2, 2022. This is my best understanding of the law but is provided for general educational purposes only. Before relying on the information on this page, clinicians should consult their malpractice insurance and, if applicable, the concerned health insurance company.
Why and how to opt out of Medicare
Pharmacy benefit managers
American Psychiatric Association. No Surprises Act Implementation
Centers for Medicare and Medicaid Services. Surprise billing & protecting consumers
Centers for Medicare and Medicaid Services. New protections for you.
Centers for Medicare and Medicaid Services. Understanding costs in advance.
Centers for Medicare and Medicaid Services. Resolving billing disagreements
Centers for Medicare and Medicaid Services. Medical bill disagreements if you’re uninsured
Centers for Medicare and Medicaid Services. Overview of rules & fact sheets
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Disclaimer: The content on this website is provided as general education for medical professionals. It is not intended or recommended for patients or other laypersons or as a substitute for medical advice, diagnosis, or treatment. Patients must always consult a qualified health care professional regarding their diagnosis and treatment. Healthcare professionals should always check this website for the most recently updated information.
Adriel Gerard says
In your interpretation, for out-of-network providers providing care to patients who submit invoices for our-of-network reimbursement to their health insurance, must GFEs be provided to these patients?
Rajnish Mago, MD says
Dr. Gerard: Yes, my understanding is that a GFE is needed for all out-of-network care, whether completely or partially paid for out of pocket.