{"id":14214,"date":"2021-09-07T15:07:37","date_gmt":"2021-09-07T15:07:37","guid":{"rendered":"https:\/\/www.medicalbillersandcoders.com\/blog\/?p=14214"},"modified":"2025-10-13T13:07:24","modified_gmt":"2025-10-13T13:07:24","slug":"surprise-billing-what-providers-must-know","status":"publish","type":"post","link":"https:\/\/www.medicalbillersandcoders.com\/blog\/surprise-billing-what-providers-must-know\/","title":{"rendered":"Surprise Billing: What Providers Must Know"},"content":{"rendered":"

Requirements Related to Surprise Billing<\/span><\/h2>\n

Biden-Harris Administration, through the U.S. Departments of Health and Human Services (HHS), Labor, and Treasury, and the Office of Personnel Management, issued \u2018Requirements Related to Surprise Billing; Part I, \u2018an interim final rule that will restrict excessive out of pocket costs to consumers from surprise billing and balance billing. <\/span><\/p>\n

Surprise billing happens when people unknowingly get care from providers that are outside of their health plan’s network and can happen for both emergency and non-emergency care. Balance billing, when a provider charges a patient the remainder of what their insurance does not pay.\u00a0<\/span><\/p>\n

Surprise bills lead the list of affordability concerns for many families; 2 in 3 adults say they worry about unexpected medical bills, more than the number worried about affording other health care or household expenses. <\/span><\/p>\n

Among privately insured patients, an estimated 1 in 5 emergency claims and 1 in 6 in-network hospitalizations include at least one out-of-network bill. Balance billing on surprise medical bills can reach hundreds or even thousands of dollars.\u00a0<\/span>Surprise medical bills are not a problem today under public programs i.e., Medicare and Medicaid<\/a> both prohibit balance billing.<\/span><\/p>\n

The No Surprises Act contains key protections to hold insurers harmless from the cost of unanticipated out-of-network medical bills. Surprise bills arise in emergencies when patients typically have little or no say in where they receive care. <\/span><\/p>\n

They also arise in non-emergencies when patients at in-network hospitals or other facilities receive care from ancillary providers (such as anesthesiologists) who are not in-network and whom the patient did not choose.<\/span><\/p>\n

This rule will provide protection to Americans insured through employer-sponsored and commercial health plans. A health plan that generally doesn\u2019t cover out-of-network care, such as an HMO, might deny a surprise bill entirely. <\/span><\/p>\n

Or plans might pay a portion of the bill, but leave the patient liable for balance billing, the difference between the undiscounted fee charged by the out-of-network provider and the amount reimbursed by the private health plan. The law contains key provisions to protect consumers against the cost of surprise medical bills.\u00a0<\/span><\/p>\n

Balance Billing is Prohibited\u00a0<\/span><\/h2>\n

Out-of-network providers for emergency services are not allowed to balance bill patients beyond the applicable in-network cost-sharing amount for surprise bills.\u00a0 This same requirement applies to out-of-network providers who render non-emergency services at an in-network hospital or other facilities.\u00a0 <\/span><\/p>\n

An exception applies for certain non-emergency services if providers give prior written notice at least 72 hours in advance and obtain the patient\u2019s written consent. The notice must indicate the provider does not participate in the network, provide a good faith estimate of out-of-network charges, and include a list of other participating providers in the facility whom the patient could select. <\/span><\/p>\n

This exception does not apply for ancillary services (such as anesthesia) or diagnostic services (such as radiology and lab) nor to other services or providers the Secretary may specify in regulation.<\/span><\/p>\n

Out-of-network providers can\u2019t Bill Excess<\/span><\/h2>\n

No Surprises Act specifies that providers \u2018shall not bill, and shall not hold patients liable\u2019 for an amount that is more than the in-network cost-sharing amount for such services. The \u2018shall not bill\u2019 language did not appear in earlier bill versions and constitutes an additional element of consumer protection under the new law. <\/span><\/p>\n

Essentially it puts the burden on out-of-network providers to determine a patient\u2019s insurance status and the applicable in-network cost-sharing for the surprise medical bill.\u00a0 Absent the \u2018shall not bill\u2019 language, nonparticipating providers might continue to bill patients for the full amount, and only later refund excess amounts when and if patients learn surprise billing protections apply.<\/span><\/p>\n

In summary, no surprises act:\u00a0<\/span><\/h2>\n