Understanding ‘No Surprises Act’ as it becomes law

The recently enacted No Surprises Act, which aims to protect patients against hospitals, care providers adding costs to the bills in case of an emergency, has wider ramifications for different players in the healthcare industry. As payers and providers adopt to new norms, we look at its implications for stakeholders: 

1. Patient protection: Even though the law is not expected to provide complete billing protection, it will likely lessen patients’ worries during emergencies when patients are unable to plan in-network hospitalizations. Biggest relief for a patient would be the fact that outside providers won’t be able to charge more than the estimate given by the in-network provider. However, on a flip side, patients, in some cases, may end up receiving the entire bill if the insurer doesn’t cover anything outside its network.
2. What it means for insurers: The law also provides various other safeguards against claim rejections by the insurer during emergency visits. This will impact insurance providers in a big way since they have been trying to narrow down the claims to only life-threatening emergencies. However, the No Surprises Act makes it clear that an insurer can’t deny a claim just based on the diagnosis of a doctor and they must take into account the symptoms an ‘emergency’ patient had during admission to emergency.
3. Twist in the tail?The law still has enough scope for a doctor outside of network, asking a patient, who is not an emergency one, to waive off their protection in return for giving them an estimate of what could be the cost of the treatment. Once they sign the waiver and the actual bill amount is $400 or more than the estimate then a patient has a four month window to contest it before an authority as provided in the law.
4. Dispute resolution mechanism: The act SA makes it mandatory to set up an independent dispute resolution process. In case of uninsured patient, the arbitrator helps in resolution between the provider and the patient. In case of insured patients, the two parties involved are the provider and the insurance company. In such a scenario, the losing party will have to bear the costs.
5. Aims at transparency: The No Surprises Act provides for added transparency in the dealings between patient, provider and payer. As per provisions of the law, providers must disclose any provisions for balance billing and cost-sharing to patients. They have to also check if the patient is insured or not. Health plans are also to update their provider databases once every three months so that a patient gets the latest information about the provider and network.