UNPACKING THE NO SURPRISE ACT

It is our third year of the epidemic and hospitals, clinics and practitioners are stressed over labor shortages, financial stress, and extremely sick patients. Effective January 1, 2022, the No Surprise Act (NSA) adds more complexities to health care.

Surprise medical bills occur when insured consumers inadvertently receive care from out-of-network hospitals, doctors, or other providers they did not choose. It has impact on:

• Emergency services.
• Non-emergency services provided by non-participating providers who staff at a participating provider institution.
• Air ambulance services.
• Uninsured and self-pay patients.

The following rules apply:

• Surprise bills are prohibited for most emergency services, even if the provider is out of network and did not seek prior authorization. Co-pays and deductibles need to be based on in-network rates.
• Out-of-network charges and balance billing is prohibited for certain services furnished by out-of-network providers as part of a patient’s visit to an in-network facility. This has impact on specialties such as anesthesiology, pathology, neonatology, lab services and radiology.
• Air ambulance services, even if out-of-network, are covered.
• Uninsured and self-pay patients must be provided a good faith estimate as to treatment and, if the charges end up being $400 higher than the estimate, the patient can contest the charge.
• Perhaps the most consequential change is that an out-of-network provider, rather than directly billing a patient for out-of- network service, must submit the bill to the insurer of the patient and after payment is received then submit the balance bill to the patient. The insurer must pay or deny the claim within 30 days of submission.
• Network directory information on physician choice is binding on the insurer.
• Patient payments in excess of in-network cost sharing must be refunded.
• A provider need not comply with these rules if the patient provides prior written consent. The consent form, however, is arduous.
• An independent dispute resolution (IDR) process is established for determining the payment for a “Surprise” billing, beginning with negotiations between plans and providers.
• Providers and facilities must post a one-page disclosure notice summarizing the NSA surprise billing law on a public website and give this disclosure to each patient for whom they provide NSA-covered services.

While the NSA is a federal law, it will be enforced by state government. In Minnesota both the Department of Commerce and the Department of Health will share responsibility for enforcement.

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431 S Seventh Street, Suite 2545
Minneapolis, MN 55415
612-315-3037

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Swanson | Hatch, P.A.
431 S. 7th Street, Suite #2545
Minneapolis, MN 55415
612-315-3037
www.swansonhatch.com