No Surprises Act Effective January 2022

The No Surprises Act went into effect January 2022 as part of the Consolidated Appropriations Act of 2021.  The purpose of the Act is to address surprise or balance billing that health plans charge when you use out-of-network providers.  It prohibits insurers from charging higher rates or denying claims for care obtained from out-of-network providers for emergency services, and in some cases, certain services provided by out-of-network clinicians at in-network facilities.  It stipulates that the health plan must cover these services as if they were in-network.

The Act also requires insurers to send beneficiaries an Advanced Explanation of Benefits (AEOB) for upcoming procedures or services as a “good faith estimate” of the costs that you will incur.  Provided information in these AEOB’s should cover whether each provider or facility is in-network or out-of-network, the contracted rate of the service, how to obtain only in-network providers, all expected charges, any cost-sharing amounts and whether prior authorization (or other stipulations) apply.

Many plans may try and get around these requirements by having you sign a Surprise Billing Protection Form.  Think carefully before signing this form as it may limit your consumer protection rights.  It essentially says that you are willing to pay out-of-network rates for any services administered by out-of-network providers. The form must be given to you at least 72 hours before you receive care, and a good faith estimate should be included on the form. Providers prohibited from giving you this form include emergency room doctors, anesthesiologists, assisting surgeons and radiologists.