WHAT YOU NEED TO KNOW
The No Surprises Act

The No Surprises Act (NSA) went into effect on January 1, 2022 and will have implications for patients, employers, health plans, and providers. The law prohibits medical balance bills for many – but not all – out-of-network (OON) services when the member cannot control where or who they receive care from.

WHAT THE NSA COVERS

The No Surprises Act focuses on three main areas:

1

Prohibits surprise medical billing for out-of-network emergency and air ambulance services.

2

Prohibits surprise medical billing for services performed by out-of-network providers at an in-network facility.

3

Establishes a dispute resolution process for providers and insurers.

 

WHAT THE NSA DOES NOT COVER

Not all situations are covered by the No Surprises Act

In general, if a patient chooses to receive care out-of-network, The No Surprises Act will not apply.

So, if you choose to see a doctor or specialist who is not in-network, The No Surprises Act and its protections will not apply, and you may face much higher costs than if you chose a network provider.

The No Surprises Act also does not protect patients from balance billing for ground ambulance services, or when the law’s notice and consent requirements are met.

 

NSA BY THE NUMBERS

45%

45% of Americans worry that a major health event will bankrupt them.*

70%

70% of out-of-network medical bills come from situations that won’t be covered by the No Surprises Act.^

40%

More than 40% of people who received an out-of-network bill report costs over $500.*

  • * Source: KFF.org
    ^ Based on UHC commercial claims data from 2020-2021.

 

What the No Surprises Act means for Patients, Employers and Providers.

Learn more about how the No Surprises Act affects patients, employers, and healthcare providers.

NO SURPRISES ACT FOR PATIENTS
home patients NSA for Patients
NO SURPRISES ACT FOR EMPLOYERS
NSA for Employers
NO SURPRISES ACT FOR PROVIDERS
home providers NSA for Providers

Naviguard can help

Naviguard provides a better solution for complex out-of-network billing. Our deep industry knowledge positions us to understand and explain this new legislation from the point of view of patients, employers, providers and insurers.

We have helped over 140,000 patients and saved our members over $85 million on their out-of-network medical bills. We are here to help providers and health plans work through the new requirements and administer them appropriately for their facilities, patients, and members.

 

Video: No Surprises Act Overview

What is the No Surprises Act, how does it work, and how can Naviguard help?
We break it down for you here.

Weekly Dose Podcast: Taking the Surprise out of Surprise Medical Bills

One of the most important pieces of health care legislation was signed into law last December. The No Surprises Act was designed to protect consumers from surprise medical bills, those medical bills that come unexpectedly and often with high price tags. But heading into 2022, hospitals and insurers are still trying to determine how to implement the legislation’s requirements. So what’s at stake with the legislation? And how does it affect patients, hospitals and insurers?

Michael Wentzien of Naviguard and Lisa McDonnel of UnitedHealthcare explain in this episode.

podcast image
UnitedHealth Group Weekly Dose Podcast | EP22
Taking the Surprise Out of Surprise Medical Bills
Recast
PRIVACY
Weekly Dose Podcast: Taking the Surprise out of Surprise Medical Bills

One of the most important pieces of health care legislation was signed into law last December. The No Surprises Act was designed to protect consumers from surprise medical bills, those medical bills that come unexpectedly and often with high price tags. But heading into 2022, hospitals and insurers are still trying to determine how to implement the legislation’s requirements. So what’s at stake with the legislation? And how does it affect patients, hospitals and insurers?

Michael Wentzien of Naviguard and Lisa McDonnel of UnitedHealthcare explain in this episode.

UnitedHealth Group Weekly Dose Podcast | EP22
Taking the Surprise Out of Surprise Medical Bills
Recast
PRIVACY
podcast image

No Surprises Act FAQs

  • The No Surprises Act prohibits out-of-network providers from pursuing members directly for medical balance bills in situations where the patient has little or no control over who provides their care. This includes all emergency services (except ground ambulances), or when an out-of-network provider is involved in their care while they are at an in-network facility. As a result, patients will be protected from balance bills in most situations where they have little or no control over who provides their care.

    However, the No Surprises Act does not apply if the member chooses to receive items and services from an out-of-network provider. The law also does not apply for ground ambulance services, or when the law’s notice and consent requirements are met for certain non-ancillary services provided at in-network facilities.

    The No Surprises Act also establishes an Independent Dispute Resolution (IDR) process, also referred to as arbitration, to resolve disputes between OON providers and insurers/health plans.

  • Under the law, effective upon plan years beginning on or after January 1 2022, out-of-network providers are prohibited from pursuing members directly for balance medical bills in situations where they have little or no control over who provides their care, like for all emergency services (except ground ambulance), or when an out-of-network provider is involved in their care while they are at an in-network facility.

    If a patient receives a service that is covered by the No Surprises Act, the law caps the patient’s cost share to what it would be if the services were provided in-network.

  • Patients are protected from balance bills when they receive:

    • Out-of-network emergency services, including air ambulance (but not ground ambulance)
    • Covered medical items and services performed by an OON provider at an INN facility (unless non-ancillary services and the provider follows the notice and consent process ).
    • Out-of-network non-emergency, ancillary services* provided at in-network facility.
    • Non-emergency, non-ancillary services provided at in-network facility, and the provider did not get your prior consent in the way the No Surprises act requires.

     

    And, for the above services, your cost-share (in other words, your coinsurance, copay, deductible):

    • Is the same as it would have been if the service was provided in-network.Counts toward your in-network deductible.
    • Counts toward your out-of-pocket maximum.

     

    *Ancillary services include services related to emergency medicine, anesthesiology, pathology, radiology and neonatology; certain diagnostic services (including radiology and laboratory services); items and services provided by other specialty practitioners; and items and services provided by an out-of-network provider if there is no in-network provider that can provide that service.

  • You can find an explanation of what out-of-network laws are currently in place in your state here.

    The law may not pre-empt state balance billing laws that establish a process for determining OON reimbursement for covered items and services for insurers subject to the state’s law.

  • The No Surprises Act is effective for plan years when they commence on or after January 1, 2022.  Therefore, if a plan renews during 2022, the No Surprises Act will go into effect on the renewal date.

    For example, if a plan year commences on December 1, 2022, the No Surprises Act will go into effect on that date.

  • Insurer and health plans: provisions applicable to insurers and health plans are enforced by the applicable federal agency (the Departments of Health and Human Services, Labor, and the Treasury).

    Providers and facilities: provisions applicable to health care providers and facilities are enforced by the Department of Health and Human Services which may impose fines of up to $10,000 per violation.

    States: provisions applicable to providers and facilities (including air ambulance) may be enforced by the states.

 

CONTACT US

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Have a question for Naviguard or want to learn more about our out-of-network medical bill services?

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