The Latest on Surprise Billing

An important part of the Consolidated Appropriations Act of 2021 is the No Surprises Act, intended to address surprise bills and protect healthcare consumers who receive a “balance bill” for amounts charged by a provider but not paid by their health plan. The law, scheduled to take effect on January 1, 2022, will protect patients that go to an out-of-network facility for emergency treatment, patients needing to be airlifted to the nearest emergency room by an out-of-network provider and patients receiving treatment from an out-of-network provider at an in-network facility.

The new law establishes uniform, basic federal requirements for insured and self-funded group health plans, however states may adopt even stricter standards for insurers and providers in their jurisdiction. To date, 17 states have adopted comprehensive balance bill laws to protect their residents. Guidance for several situations will need to be provided prior to year-end, including how plans will distinguish between in-network and out-of-network providers in self-funded plans using reference based pricing without a traditional PPO network. Industry sources expect these regulations to be issued by mid-year.

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