Is Your Medical Practice Adhering to the No Surprises Act?

 Posted on August 26, 2022 in Medical License Defense

On January 1, 2022, the No Surprises Act (NSA) went into effect. This federal law gives doctors and other licensed health care professionals, medical facilities, hospitals, and insurers significant and often complex regulations that must be adhered to in order to avoid serious sanctions that could include hefty fines and loss of medical licenses.

What Does the NSA Cover?

Lawmakers passed the NSA as a way to protect patients from unexpected medical charges and force providers to be more transparent when it comes to what they are charging. National statistics show that at least 20 percent of patients have received shocking emergency medical care bills with unexpected charges at some point in their lives.

The law limits the amount of liability a patient has on deductibles, copays, and coinsurance they are responsible for if situations prevent them from obtaining services from providers in their health insurance network and they are forced to obtain medical treatment from out-of-network providers at in-network facilities. 

The NSA essentially limits patient liability in these situations to the same coinsurance, deductibles, or copay amounts they would have been responsible for if a participating provider within the patient’s insurance plan network had performed the services. This comes up in the context of “balance billing” – the medical provider's practice of billing the patient for the amount not paid by insurance.

The goal of the NSA is to prevent patients from receiving these surprise bills in situations such as:

• Any emergency care that is obtained from out-of-network providers and facilities

• Ambulance services by helicopter or plane that is out-of-network

• Any medical services provided by nonparticipating medical professionals that work at in-network facilities

If forced to go out of network, the patient is only responsible for the same cost-sharing amount they would have been liable for if they had received the same medical care in-network. The only exception to this rule is if the patient had received prior notification of the higher costs and had agreed to the treatment under those prices. But there are even exceptions under this rule – there are numerous medical specialties this rule does not apply to, including anesthesiology, neonatal treatment, and radiology.

NSA Provides Continuity of Care

Another provision of the NSA states that if a patient is being treated for a long-term or ongoing “serious and complex condition” from in-network providers and/or facility and that provider or facility later becomes out-of-network, they must continue to bill the patient at the in-network pricing.

Penalties for Violating the NSA

As mentioned above, the NSA is a massive law, full of complex regulations that contain very specific requirements. Violations of these regulations can be costly – a provider or facility can be fined up to $10,000 per violation.

Contact an Illinois Professional License Defense Attorney

If you are confused by the requirements of the NSA or have been notified of potential violations, do not delay in contacting The Law Offices of Joseph J. Bogdan, Inc. at 630-310-1267 to schedule a confidential consultation with one of our dedicated Illinois provider enrollment defense lawyers and find out what legal options you may have against these allegations.

Source:

https://www.kff.org/private-insurance/fact-sheet/surprise-medical-bills-new-protections-for-consumers-take-effect-in-2022/