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  • Writer's pictureLedbetter Parisi LLC

Congress Passes Law Limiting Surprise Balance Billing

The No Surprises Act, which was included in the omnibus Consolidated Appropriations Act signed into law by President Trump in late December 2020, aims to protect consumers from surprise medical bills beginning in 2022. The Act requires that health plans pay providers for certain charges that would otherwise have been balance billed to the patient. The Act applies to out-of-network emergency services, including air ambulance but excluding ground ambulance services. The act also applies to services provided by out-of-network providers at a network facility, such as services provided by an out-of-network anesthesiologist at a network hospital.

Generally, the legislation limits a patient’s out-of-pocket costs to what they would have paid had the service been provided within the network.

In order to determine how much the health plan will pay for these services, health plans and medical providers will first attempt to negotiate on their own. If they cannot come to a mutual decision on payment within 30 days, they then may initiate a binding arbitration process. Both parties will submit payment offers and evidence to the arbitrator, who will then select one of the amounts based on multiple factors, including the median in-network rate; the provider’s experience and education; the type and complexity of the service; and prior contracted rates. Both parties are bound by this decision, and the losing party must pay the cost of arbitration. This process differs from previous versions of the bill, where a benchmark payment standard would have been established to determine the amount owed to out-of-network providers.

The legislation has directed the Departments of Labor, Health and Human Services, and Treasury to issue regulations by January 2022, which will provide more details before enforcement begins.

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