The No Surprises Act that is to be effective from January 2022, has now restricted payers and providers from easily billing the patient for out-of-network services. Though this is to prevent any unjust billing against patients, it’s for sure a small hiccup, especially for providers. There is speculation against this Act among industry experts in determining if it will really benefit patients by increasing their access to better healthcare.

This Act comes into play when patients seek care from out-of-network hospitals and providers, in case of emergency situations. Patients can usually only choose their primary care provider and the facility, but do not have control over the anesthesiologist and other physicians. This Act is also applicable for air ambulance services and out-of-network providers, for services they render at an in-network hospital, even during the time of elective care. Providers and payers must consider such services as in-network services and bill according to in-network rates. Another important point to be noted about this Act is that it prohibits balance billing as well, for emergency services.

When looking at this from an overall perspective, ultimately it is the Medical service providers who have to make a lot of adjustments. This Act also forces providers to remain or move from being an out-of-network provider, as it does not change the reimbursement rates and can also help in increasing payments through arbitration. On the other hand, there may be changes to the in-network rates from the payers, so has to prevent providers from becoming out-of-network. Such highly confusing and unstable payer dynamics, only increases the burden for the providers.

Usually, out-of-network providers had the right to bill the patient a higher rate than that is usually reimbursed for in-network providers. Now that the Act prohibits that, providers take a hit on their income even after provider care to out-of-network patients. Providers have to possess complete knowledge of every plan’s QPA (Qualifying Payment Amount) which is the median rate of every plan (as per in-network or contracted rate).

The No Surprise Act has forced providers to become more aware when providing care as an out-of-network provider. The Act bans providers from treating patients without prior notice to the patient. This notice has to have a clear explanation in simple terms that the patient is thereby agreeing to receive care at on an out-of-network basis and is consenting with the provider billing on the out-of-network reimbursement rates, which may be higher than regular or contracted rates. Providers are now required to present a correct estimate of the charge when an uninsured or self-insured patient raises a request prior to an appointment and the responses to the said request are to be completed within a stipulated time period. Such patient requests fall under the Good Faith estimate regulations.

The chances of receiving care from an out-of-network provider are surprisingly high in reality and there is no doubt that this Act does protect the interests of patients against large surprise bills, but there are a lot of hindrances for providers as well. It is time providers get educated and make themselves aware of every guideline of this Act. There is definitely a challenge for providers to find the time for patient care and handle medical claims.

The Act opens the doors to a good opportunity for providers to outsource their Revenue Cycle to Medical Billing companies. This Act sure needs a check on the credentialing of providers and also requires constant monitoring of various payers’ reimbursement rates (QPA) so as to bill accurately. Providers can leave it to the experts like Medical Billing service providers and not worry about the No Surprise Act of having any impact on their income.