No Surprises Act Explained

The No Surprises Act Went Into Effect on January 1, 2022.

Approximately 20% of ER Visits and 9%-16% of Hospitalizations Results in a Surprise Out-of-Network Medical Bill to Patients.

The No Surprises Act Requires Health Insurance Companies to Apply Out-of-Network Bills to Member's In-Network Deductible and Co-Insurance.

The No Surprises Act Also Requires Out-of-Network Doctors to Not 'Balance-Bill' Patients for Any Additional Payment.

The No Surprises Act States that Insurance Companies and Providers Must Negotiate a Payment Amount for Out-of-Network Bills Using the Qualifying Payment Amount (QPA) as Guidance.

The QPA is the Medical In-Network Allowed Amount an Insurance Company Pays Providers for a Medical Service in a Particular Geographic Area.

The Texas Medical Association Recently Sued Regarding the QPA and a Federal Judge Sided with them Saying that the QPA Cannot be the Sole Determinant of the Amount Paid by the Insurance Company to the Provider.

Sources:

AHealthcareZ is 200+ Healthcare Finance Educational Videos.

AHealthcareZ Viewers Include: Employee Benefits Professionals, HR, CFOs, Insurance Brokers, Benefits Consultants, Doctors and Nurses in Leadership Roles, Hospital and Health System Administrators, Health Insurance Carrier and PBM Professionals, Pharma and Med Device Professionals, Academic Professors and Students in Healthcare Administration and Public Health.

90,000+ Views Per Month Across All Platforms.

Visit AHealthcareZ.com to Subscribe to the Healthcare Finance Video Newsletter.

[victorco.]

I am shocked, lawmakers did not care about basic patient protection till 2022?

[williamdavidson]

Thank you for your informative video. Recently, I received a GFE of $119.00 about a month before a regular doctor visit at the Banner health clinic in Peoria, AZ. I'd been going to this clinic every 6 months for about 10 years and always paid my bill before leaving. 6 MONTHS later, Banner sent me a surprise bill for $56.00, for which nobody in the company - even their office manager could explain why. I asked them if they were aware of the "No Surprises Act" to which they were all clueless. Their answer instead was to send me to a collection agency. And all over $56.00....😳

[rendiego]

Great video Dr. Bricker as always. I remember from way back, probably 10 years back when you / Compass helped one of our clients negotiate down an air ambulance bill when it was completely unnecessary for the company to use air ambulance. Helped save that employee and her spouse around $40K. Keep up the good work!!

[Just.D]

My Doctor said I did not need pre authorization for surgery and I did. I just got a 10, 000$ bill. I am appealing it now.

[djphanatik]

If the insurance companies weren’t so devious and deceptive we wouldn’t be in this situation

[zaboomafoo]

thank you for the info...and, we should all remember, The Customer Is Always Right ....

[cguzman]

Wow, I was hoping a solution on how to fight a bill.

[ecaldwell]

How do we go about getting a copy of the Poster that has to be posted in waiting Rm? I’m in IL.

[nikki.]

What about being fully covered in your state so you have your procedure 100% covered but they send a biopsy out of state(in network so they claim) so you now get billed triple digits bc it was sent out of state so it goes towards your out of network deductible now?!

[DiegoKeel-clov]

Not sure where to post this question, so I put it under this video which had a similar topic. My Doctors office called me (unsolicited) and left a voicemail to call them back. When I called back, nurse asked me if I needed a refill prescription for my meds. I said no, but she continued to ask questions. Finally hung up just after 3 minutes. Two months later I get billed for an office visit for$350. This can’t be legal. Could you please let me know what I can do to dispute this? Or maybe this could be a topic for one of your short videos? Thanks

[susanf]

My insurance says that my ER copay is $100. I went to an in network hospital. But I'm seeing radiology claims that are out of network because nothing was paid. There are in network discounts on those claims. They still say processing. Are they going into arbitration? I thought I only pay the copay no matter what.

[lk]

What about self paid patients that weren't explained what the visit will incur with the lab fees for example

[TruxEffects]

Could you tell me if this would help with an emergency air helicopter bill of 62k. Our insurance denied coverage saying it is not covered under our plan. 62k is an insane amount that is well over the national average. This was not elected either.

[ecaldwell]

Are there any exceptions to this Act for Encounter Rate Billing?

[leanaramos]

Hello Dr. Bricker, an in-network doctor sent pathology to an out-of network lab. I had a procedure done at my doctor’s private practice office. The doctor is in-network with my insurance. They then sent a specimen to an out-of-network pathology lab. The doctor never informed me that his office would be sending the specimen to an out-of-network pathology lab. I never signed a consent form for this. I am now receiving a notification from my insurance that the insurance claim has been denied because the pathology lab was out-of-network. I have a bill of over $400. Legally, do I have anything that can help me avoid having to pay for this? By the way, I live in Florida, US.

[kylecaudill]

what about an in nerwork doctor billing out of network hospital all of a sudden after the 5th visit?

[maryspaeth]

How will this work with an RBP plan? Is that another video subject all together for you?

[christinadorman]

My doctor now has to wait for my insurance company to the okay something this wasn't done before is that part of the surprise act bill?

[peterbychowski]

Does this affect bills from procedures that were before 2022? I'm disputing a balance bill from 2020 currently and was wondering if this would apply

[chandlerkatz]

Does the balance billing aspect of the NSA apply to RBP?