An End to Surprise Medical Bills

I don’t know about you, but I’m not that big on surprises, especially when they come in the form of a bill from a medical provider that I thought was in my health plan’s network. This happened to me once when I was traveling and ended up in a hospital emergency room. My health plan covered emergency room care at 100% as long as I used an in-network facility, which I did. What I didn’t know was that the attending physician was not in my health plan’s network. I was billed a surprisingly large amount for those services. I wasn’t happy about it, but there wasn’t much I could do about it at the time. 

Well, times have changed, in the form of a new law called the No Surprises Act, included in the fiscal 2021 consolidated appropriations measure. It takes effect Jan. 1, 2022, and is designed to protect consumers from surprise medical bills under certain circumstances.

The Office of Personnel Management has the responsibility of overseeing how the law is implemented by Federal Employees Health Benefits Program providers. In the 2022 FEHBP plan brochures and on most plan websites, you will find language similar to this description in the Blue Cross Blue Shield brochure:

The No Surprises Act (NSA) is a federal law that provides you with protections against “surprise billing” and “balance billing” under certain circumstances. A surprise bill is an unexpected bill you receive from a non-participating healthcare provider, facility, or air ambulance service for healthcare. 

Surprise bills can happen when you receive emergency care—when you have little or no say in the facility or provider from whom you receive care. They can also happen when you receive nonemergency services at participating facilities, but you receive some care from non-participating providers. 

Balance billing happens when you receive a bill from the non-participating provider, facility, or air ambulance service for the difference between the non-participating provider’s charge and the amount payable by your health plan. 

Your health plan must comply with the NSA protections that hold you harmless from unexpected bills.

Keep in mind that you might choose to use a non-participating provider when you seek medical care, especially if your health plan provides benefits for out-of-network services. According to a recent Reedsmith article, the No Surprises Act provides exceptions to the balance billing prohibition if, for example, an adequately notified patient consents to receive services from an out-of-network provider at an in-network facility. Under these circumstances, the additional cost isn’t considered a surprise. 

According to the Kaiser Family Foundation, surprise bills can number in the millions each year. Among privately insured patients, an estimated one in five emergency claims and one in six in-network hospitalizations include at least one out-of-network bill. A 2020 report found 39% of insured nonelderly adults said they had received an unexpected medical bill in the previous year, and about 10% said the bill was from an out-of-network provider. Of those who received an unexpected bill, 13 percent said the costs were $2,000 or more.

According to a recently released fact sheet from the Centers for Medicare and Medicaid Services, the No Surprises Act also provides other consumer protections, including:

• A process that takes consumers out of the middle of payment disputes between providers and health plans.
• Requirements for health care cost estimates to be provided to uninsured or self-paying patients.
• A payment dispute resolution process for uninsured or self-paying patients.
• Expanded rights to external review when certain claims are denied payment. 

The Congressional Budget Office has projected that the No Surprises Act will reduce private health plan premiums by up to 1% on average, and reduce the federal budget deficit by $17 billion over 10 years.

The new rules don’t apply to people with coverage through programs such as Medicare, Medicaid, the Indian Health Service, the Veterans Affairs health system or TRICARE, because these programs already have other protections against high medical bills.