No Surprises Act: Regulations, Penalties and Deadlines From the New Law

Passed in 2021, the No Surprises Act is a piece of legislation designed to protect consumers from surprise medical bills. While focused mainly on preventing surprise bills from larger medical providers like hospitals and emergency services, there are potential implications for smaller healthcare providers as well.

The No Surprises Act went into effect on January 1, 2022, and many medical offices across the U.S. are working to keep their practice compliant with the new regulations. Despite the focus of the legislation being on hospitals and emergency services, small healthcare practices can still be impacted, experts say.

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Here, we’ll give an overview of the No Surprises Act and help healthcare providers and practices understand its potential impact on their business and its operations.

New rights and regulations

Under the No Surprises Act, people covered by group and individual health plans are protected from surprise medical bills after receiving most emergency services, non-emergency services from out-of-network providers at in-network facilities, and healthcare services from out-of-network air ambulance service providers.

This law also establishes a resolution process for payment disputes between plans and providers. New dispute resolution opportunities are likewise provided for uninsured and self-pay individuals that have received a medical bill that exceeds the good faith estimate they got from their provider.

For people with private health insurance, the protections provided by the No Surprises Act ban the most common types of surprise bills. The uninsured and those not using their health insurance for a service can get a good faith estimate of the cost of care before their visit under the No Surprises Act. Then, if they disagree with the bills, they have the ability to dispute the charges.

Previously, consumers with health insurance receiving care from out-of-network providers and facilities may not have had their out-of-network cost covered. These situations often led to significantly higher costs than in-network care. Health insurance plans would pay their portion, then out-of-network providers would charge for the remainder of the bill in a process called “balance billing.”

While individuals with Medicare and Medicaid are already protected from surprise medical bills, the No Surprises Act extends these protections to those with other group and individual health insurance. For those receiving coverage through their employer or individual health insurance plans, the No Surprises Act offers the following protections:

• A ban on surprise bills for most emergency services, including out-of-network services;
• A ban on out-of-network costs for most emergency and some non-emergency services, meaning you can’t be charged more than you would in-network;
• A ban on out-of-network charges for additional services (like anesthesiology or radiology) resulting from a patient’s visit to an in-network facility; and
• A requirement that providers and facilities offer an explanation of billing protections.

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Actions for healthcare providers and facilities

What can healthcare providers and facilities do to ensure they’re fulfilling the No Surprises Act’s requirements? Here are three important considerations to make when reviewing your practice’s current compliance with the new legislation. Always consult with your legal counsel to ensure your practice is fully compliant.

1. Review your public disclosures

The No Surprises Act requires healthcare facilities and providers to provide patients with a one-page, simple explanation of the law. The legislation outlines that this disclosure must give patients information about what the No Surprises Act entails, as well as guidance on the process for contesting violations.¹ The No Surprises Act also notes that the disclosure must also be available to the public through the provider’s website.

2. Audit your balance billing processes for out-of-network patients

Formerly, healthcare providers could bill out-of-network patients directly. Now, providers have to determine which patients are in-network and which are out, then negotiate payments with out-of-network patients with the patients’ health plans instead of having the patient sort it out with their insurance provider. So, rather than billing the patient directly, providers must rely on the health plan to decide what the patient owes.

“There are patients today that are more willing to go out-of-network,” says Dr. Edwards. “That’s one of the things that’s exciting when we look at Weave and some of the reviews we find there. There are more patients willing to go out-of-network because they believe they’re going to a superior provider.”

This wave of out-of-network patients makes it all the more important to “make sure people are clear about whether you’re in or out of network and what financial responsibilities patients will have,” says Dr. Edwards.

The No Surprises Act’s focus on patients’ financial responsibility comes as no surprise to Dr. Edwards.

“If there’s anything that will prevent the success of a patient-physician relationship, it’s money,” Dr. Edwards says. “Money seems to be the biggest factor that will delay the successful healing of a treatment rendered.”

3. Adjust written waivers

Providers can seek to have patients waive the protection of the No Surprises Act. However, the provider has to give the patient a detailed consent form 72 hours prior to a scheduled appointment or 3 hours before same-day appointments. Under the law, these consent forms must indicate whether pre-authorization is required, which in-network providers are available, and a good-faith cost estimate for the total bill of care.

Good-faith estimates are designed to push health plans toward providing an advanced explanation of benefits, including the total cost of out-of-network care and likely out-of-pocket expenses. Patients, of course, have to give consent to out-of-network treatment voluntarily. According to the Act, providers must share copies of any signed consent forms with patients, and should keep the forms for seven years. These forms should also be submitted to the health plans of patients.

“With good-faith estimates,” says Dr. Edwards, “there’s a lot more impact on smaller practices and the burden on their staff to meet some implementation requirements.”

Many offices are already juggling piles of paperwork and patient intake forms, HIPAA disclosures and additional billing and collection forms. Weave’s recent survey of patients found that 58% consider filling out paper intake forms “old fashioned.” If you want to learn more about digital forms and how they can improve your office’s efficiency and operations, read more here or schedule a demo of Weave today.

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4. Potential penalties

Healthcare providers that violate the No Surprises Act are subject to civil monetary penalties of up to $10,000. These penalties don’t apply if the provider unknowingly violates the new law. If an unknowing violation has been made, providers can avoid penalties if they withdraw the bill within 30 days and reimburse payments received plus interest.

Does the No Surprises Act apply to dental practices?

According to the American Dental Association, the No Surprises Act’s protections against balance billing largely do not affect private dental offices because dental benefits are excepted benefits.

The ADA believes that “if the dental component is an excepted benefit, most dentists will not have to worry about making that determination initially,” although “the exception would be in rare instances where the dispute resolution and arbitration requirements apply to dental because they are site specific to hospitals and ambulatory centers.”

Does the No Surprises Act apply to optometry practices?

The American Optometric Association has also released statements regarding the No Surprises Act. Their organization says that the new rules are targeted primarily at facilities such as hospitals that provide both emergency and non-emergency care.

The AOA did ask the government for clarification on how the requirement of good faith estimates (GFE) applies to individual physician practices. The Department of Health and Human Services responded by saying that, “Generally, all providers and facilities that schedule items or services for an uninsured (or self-pay) individual or receive a request for a GFE from an uninsured (or self-pay) individual must provide such individual with a GFE. No specific specialties, facility types, or sites of service are exempt from this requirement.”

HHS also indicated that if this comprehensive good faith estimate is provided orally, optometry practices must follow up with a written estimate.

What about veterinarians?

The No Surprises Act does not apply to veterinary practices.

When does the No Surprises Act take effect?

The No Surprises Act took effect on January 1, 2022. Healthcare providers with questions about policies and resources should visit the No Surprises Act website to get a better grasp on how the legislation might impact their practice and what they can do to ensure patients are being billed properly.

Keep in mind, we aren’t your lawyers, so we cannot give you legal advice. Compliance with the No Surprises Act and other applicable laws and regulations will depend on your particular use case and context. This information should not be relied upon as legal advice or to determine how legal requirements apply to your use of the Weave service. We encourage you to seek guidance from your legal counsel regarding the requirements of the No Surprises Act and other relevant laws and regulations to ensure compliance.