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  5. No Surprises Act

No Surprises Act

    The No Surprises Act (NSA) prohibits balance billing insured patients who receive emergency or non-emergency services from out-of-network providers at in-network facilities for amounts greater than the patient’s in-network cost-sharing requirement for such services.  The NSA also establishes a payment dispute resolution process and requirements to provide good faith estimates to uninsured or self-pay patients.  (Note: This rule applies to private pay patients because Medicare and Medicaid already have protections against surprise billing.)

    Ending Surprise Medical Bills - This CMS page includes fact sheets, summaries, and resources for providers and patients.  Below we highlight some key guidance related to dispute resolution:

    • Good Faith Estimates and Dispute Resolution for Providers and Facilities
      • These FAQs provide guidance on several requirements, including how rules apply to no-network and closed-network plans, requirements related to disclosures, and the calculation of the qualifying payment amount (QPA).
      • HHS tips for disputing parties offer best practices, tips, and common mistakes regarding the Independent Dispute Resolutions (IDR).
      • A clarifying rule (August 2022) addresses specific issues related to disclosures regarding the QPA and guidance for IDR entities when making payment determinations.
    • Uninsured or Self-Pay Individuals
      • These FAQs from CMS provide more clarification regarding Good Faith Estimates (GFE) for uninsured and self-pay individuals. 
    • When a patient starts payment dispute regulation (Note: Some aspects of the Independent Dispute Resolution process have changed due to a February 23, 2022, court ruling.  This guidance will be updated by CMS soon. See additional details.)
    • Administrative Fees

    AMA Surprise Billing Toolkit - This toolkit can help practices understand and comply with the No Surprises Act, including responsibilities for preparing Good Faith Estimates for self-pay and uninsured patients.

    Health plans also have obligations under this rule, particularly with respect to keeping provider directories current.  CAQH offers a 2-page summary of those requirements.

    The Consumer Financial Protection Bureau reminds debt collectors and credit bureaus not to collect on medical bills protected under the No Surprises Act.

    Enforcement Letters - CMS has published letters to help determine which surprise billing requirements are enforceable by each state or territory and which requirements CMS will enforce.