{"id":15479,"date":"2022-06-15T09:58:43","date_gmt":"2022-06-15T09:58:43","guid":{"rendered":"https:\/\/www.medicalbillersandcoders.com\/blog\/?p=15479"},"modified":"2025-06-02T07:09:00","modified_gmt":"2025-06-02T07:09:00","slug":"no-balance-billing-for-out-of-network-emergency-services","status":"publish","type":"post","link":"https:\/\/www.medicalbillersandcoders.com\/blog\/no-balance-billing-for-out-of-network-emergency-services\/","title":{"rendered":"No Balance Billing for Out-of-Network Emergency Services"},"content":{"rendered":"<h2><span style=\"font-weight: 400;\">Basics of the \u2018No Surprises Act\u2019<\/span><\/h2>\n<p><span style=\"font-weight: 400;\">The \u2018No Surprises Act\u2019 provides patients with protection from surprise medical bills under certain circumstances. The \u2018No Surprises Act\u2019 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. <\/span><\/p>\n<p><span style=\"font-weight: 400;\">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. <\/span><\/p>\n<p><span style=\"font-weight: 400;\">Even though the implementation of the \u2018No Surprises Act\u2019 started on Jan 1, 2022, most providers have a lot of confusion over its implementation and billing requirements and exceptions. <\/span><\/p>\n<p><span style=\"font-weight: 400;\">To clarify all the doubts, recently CMS has shared a document <\/span><a href=\"https:\/\/www.cms.gov\/files\/document\/faq-providers-no-surprises-rules-april-2022.pdf\"><span style=\"font-weight: 400;\">\u201cFrequently Asked Questions for Providers About the No Surprises Rules\u201d<\/span><\/a><span style=\"font-weight: 400;\">. In this article, we shared a specific part of that document to discuss \u2018No balance billing for out-of-network emergency services in detail.\u00a0<\/span><\/p>\n<h2><span style=\"font-weight: 400;\">Requirements and Prohibitions of the \u2018No Surprises Act\u2019<\/span><\/h2>\n<p><span style=\"font-weight: 400;\">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. <\/span><\/p>\n<p><span style=\"font-weight: 400;\">The new surprise billing requirements and prohibitions are as follows:<\/span><\/p>\n<ul>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">No balance billing for out-of-network emergency services\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">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.\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Providers and healthcare facilities must publicly disclose patient protections against balance billing\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">No balance billing for covered air ambulance services by out-of-network air ambulance providers\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">In instances where balance billing is prohibited, cost-sharing for insured patients is limited to in-network levels or amounts\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">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\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Plans and issuers and providers and facilities must ensure continuity of care when a provider\u2019s network status changes in certain circumstances\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Plans and issuers and providers and facilities must implement certain measures to improve the accuracy of provider directory information<\/span><\/li>\n<\/ul>\n<h3 style=\"text-align: center;\"><span style=\"color: #800000;\">Maximize the Profitability of Your <a href=\"https:\/\/www.medicalbillersandcoders.com\/speciality\/emergency-medicine-billing-medical-billing-services.html\">Emergency Medicine Practice<\/a> with Our <a href=\"https:\/\/www.medicalbillersandcoders.com\/medical-billing-companies\/medical-billing-and-coding-services.aspx\">Medical Billing Outsourcing Services<\/a> Tailored For Emergency Medicine Physicians<\/span><\/h3>\n<h2><span style=\"font-weight: 400;\">No Balance Billing for Out-of-Network Emergency Services<\/span><\/h2>\n<ul>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">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.<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">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.\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Cost-sharing is generally based on the median of contracted rates payable to in-network providers or in-network facilities.<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">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<\/span><\/li>\n<\/ul>\n<h2><span style=\"font-weight: 400;\">Exceptions to No Balance Billing Requirements for <\/span><span style=\"font-weight: 400;\">Emergency Services<\/span><\/h2>\n<p><span style=\"font-weight: 400;\">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:<\/span><\/p>\n<p><span style=\"font-weight: 400;\">The attending emergency physician or treating provider determines that the participant, beneficiary, or enrollee:<\/span><\/p>\n<ul>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">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\u2019s medical condition; and<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Is it a condition to receive a notice and provide informed consent;<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">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<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">The provider or facility satisfies any additional state law requirements.<\/span><\/li>\n<\/ul>\n<p><span style=\"font-weight: 400;\">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 \u2018No Surprises Act\u2019 or need assistance in sharing cost estimates, we can help you. <\/span><\/p>\n<p><b>Medical Billers and Coders (MBC)<\/b><span style=\"font-weight: 400;\"> is a leading medical billing company providing complete <a href=\"https:\/\/www.medicalbillersandcoders.com\/revenue-management-services.aspx\">revenue cycle solutions<\/a>. We provide reliable, cost-effective, and <a href=\"https:\/\/www.medicalbillersandcoders.com\/specialty-index.aspx\">medical specialty-specific billing services<\/a> as per your practice requirements. <\/span><\/p>\n<p><span style=\"font-weight: 400;\">To learn more about our billing and coding services, contact us at <a href=\"mailto:info@medicalbillersandcoders.com\">info@medicalbillersandcoders.com<\/a>\/ <a href=\"tel: 888-357-3226\">888-357-3226<\/a>.<\/span><\/p>\n<h2>FAQs<\/h2>\n\n\n<div class=\"schema-faq wp-block-yoast-faq-block\"><div class=\"schema-faq-section\" id=\"faq-question-1748847926445\"><strong class=\"schema-faq-question\">1. What is the &#8216;No Surprises Act&#8217;?<\/strong> <p class=\"schema-faq-answer\">The &#8216;No Surprises Act&#8217; protects patients from surprise medical bills, especially in emergency situations or when receiving out-of-network services at in-network facilities, ensuring they only pay their regular in-network cost-sharing amount.<\/p> <\/div> <div class=\"schema-faq-section\" id=\"faq-question-1748847950183\"><strong class=\"schema-faq-question\">2. What is balance billing and how does the No Surprises Act address it?<\/strong> <p class=\"schema-faq-answer\">Balance billing occurs when a provider charges a patient for the difference between what the insurer pays and the provider\u2019s full charges. The No Surprises Act prohibits balance billing for out-of-network emergency services and certain non-emergency services in in-network facilities.<\/p> <\/div> <div class=\"schema-faq-section\" id=\"faq-question-1748847985355\"><strong class=\"schema-faq-question\">3. When can out-of-network providers balance bill patients for emergency services?<\/strong> <p class=\"schema-faq-answer\">Out-of-network providers can balance bill for post-stabilization services only if specific conditions are met, such as the patient&#8217;s ability to travel to an in-network provider and providing notice and consent.<\/p> <\/div> <div class=\"schema-faq-section\" id=\"faq-question-1748848025393\"><strong class=\"schema-faq-question\">4. What should providers disclose under the No Surprises Act?<\/strong> <p class=\"schema-faq-answer\">Providers and healthcare facilities must disclose patient protections against balance billing and provide a good faith estimate of expected charges to uninsured or self-pay patients at least 3 business days before a scheduled service.<\/p> <\/div> <div class=\"schema-faq-section\" id=\"faq-question-1748848051320\"><strong class=\"schema-faq-question\">5. How can Medical Billers and Coders (MBC) help with No Surprises Act billing?<\/strong> <p class=\"schema-faq-answer\">MBC offers medical billing services that ensure compliance with the No Surprises Act, helping providers navigate billing requirements and exceptions while providing accurate cost estimates to patients.<\/p> <\/div> <\/div>\n","protected":false},"excerpt":{"rendered":"<p>Basics of the \u2018No Surprises Act\u2019 The \u2018No Surprises Act\u2019 provides patients with protection from surprise medical bills under certain circumstances. The \u2018No Surprises Act\u2019 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 [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":15480,"comment_status":"closed","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[818],"tags":[568,3459,3462,3759,3464,3463,3102,3760,3465,3460,2544,3461,3466,2754],"class_list":["post-15479","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-ems-billing-services","tag-billing-and-coding-services","tag-consolidated-appropriations-act-of-2021","tag-emergency-care","tag-emergency-medicine-practice","tag-emergency-physician","tag-health-insurance-coverage","tag-leading-medical-billing-company","tag-medical-billing-outsourcing-services","tag-medical-specialty-specific-billing-services","tag-no-balance-billing","tag-no-surprises-act","tag-out-of-network-emergency-services","tag-practice-requirements","tag-surprise-medical-bills"],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v28.0 (Yoast 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The main goal of our organization is to assist physicians looking for billers and coders, at the same time help billing specialists looking for jobs, reach the right place.\",\"sameAs\":[\"https:\\\/\\\/www.medicalbillersandcoders.com\\\/blog\"]},{\"@type\":\"Question\",\"@id\":\"https:\\\/\\\/www.medicalbillersandcoders.com\\\/blog\\\/no-balance-billing-for-out-of-network-emergency-services\\\/#faq-question-1748847926445\",\"position\":1,\"url\":\"https:\\\/\\\/www.medicalbillersandcoders.com\\\/blog\\\/no-balance-billing-for-out-of-network-emergency-services\\\/#faq-question-1748847926445\",\"name\":\"1. 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