No Balance Billing for Out-of-Network Emergency Services

Basics of the ‘No Surprises Act’

The ‘No Surprises Act’ provides patients with protection from surprise medical bills under certain circumstances. The ‘No Surprises Act’ part of the Consolidated Appropriations Act of 2021, forbids patients from receiving surprise medical bills when seeking emergency services or certain services from out-of-network providers at in-network facilities. The Act holds patients liable for their regular in-network cost-sharing amount only. It allows providers and insurance companies to negotiate reimbursement separately including through an independent dispute resolution process. Even though the implementation of the ‘No Surprises Act’ started on Jan 1, 2022, most providers have a lot of confusion over its implementation and billing requirements and exceptions. To clarify all the doubts, recently CMS has shared a document “Frequently Asked Questions for Providers About the No Surprises Rules”. In this article, we shared a specific part of that document to discuss ‘No balance billing for out-of-network emergency services in detail. 

Requirements and Prohibitions of the ‘No Surprises Act’

Patients now have new billing protections when getting emergency care, certain non-emergency care from out-of-network providers during visits to certain in-network facilities, and air ambulance services from out-of-network providers. The new surprise billing requirements and prohibitions are as follows:

  • No balance billing for out-of-network emergency services 
  • No balance billing for non-emergency services by out-of-network providers during patient visits to certain in-network healthcare facilities, unless notice and consent requirements are met for certain items and services. 
  • Providers and healthcare facilities must publicly disclose patient protections against balance billing 
  • No balance billing for covered air ambulance services by out-of-network air ambulance providers 
  • In instances where balance billing is prohibited, cost-sharing for insured patients is limited to in-network levels or amounts 
  • Providers must give a good faith estimate of expected charges to uninsured and self-pay patients at least 3 business days before scheduled service, or upon request 
  • Plans and issuers and providers and facilities must ensure continuity of care when a provider’s network status changes in certain circumstances 
  • Plans and issuers and providers and facilities must implement certain measures to improve the accuracy of provider directory information

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No Balance Billing for Out-of-Network Emergency Services

  • Out-of-network providers and out-of-network emergency facilities cannot bill or hold liable participants, beneficiaries, or enrollees who received emergency services for a payment amount greater than the in-network cost-sharing requirement. For these protections to apply, emergency services must be received at a hospital or an independent freestanding emergency department.
  • The patient must be enrolled in a group health plan or group or individual health insurance coverage. For this purpose, a Federal Employees Health Benefits plan is included as a group health plan. 
  • Cost-sharing is generally based on the median of contracted rates payable to in-network providers or in-network facilities.
  • Certain post-stabilization services are considered emergency services and are therefore subject to this prohibition unless notice and consent and certain other requirements are met

Exceptions to No Balance Billing Requirements for Emergency Services

Out-of-network providers and out-of-network emergency facilities may balance bills for post-stabilization services only if all of the following conditions have been met:

The attending emergency physician or treating provider determines that the participant, beneficiary, or enrollee:

  • Can travel using non-medical or nonemergency medical transportation to an available in-network provider or facility located within a reasonable travel distance, taking into account the individual’s medical condition; and
  • Is it a condition to receive a notice and provide informed consent;
  • The out-of-network provider or out-of-network emergency facility provides the participant, beneficiary, or enrollee with a written notice including certain information during a specific timeframe (as provided in regulations and guidance) and obtains consent to waive surprise billing protections; and
  • The provider or facility satisfies any additional state law requirements.

We share such useful content as a part of our provider education initiative. If you are not sure about billing requirements (or exceptions) under the ‘No Surprises Act’ or need assistance in sharing cost estimates, we can help you. Medical Billers and Coders (MBC) is a leading medical billing company providing complete revenue cycle solutions. We provide reliable, cost-effective, and medical specialty-specific billing services as per your practice requirements. To know more about our billing and coding services, contact us at 888-357-3226