No Suprise Act Policy

Beginning January 1, 2022, the new protections against surprise medical bills to The No Surprise Act (NSA) became effective. These new rules have been implemented to protect consumers from excessive out-of-pocket costs for emergency, post-emergency stabilization, and non-emergency services rendered from out-of-network providers at an in-network facility. 

Previously, if a patient had health insurance and received care from an out-of-network provider within an in-network facility, knowingly or inadvertently, their health plan may not have covered the entire cost, leaving a balanced owed to the patient. This is what is known as a surprise medical bill.

If a patient has health coverage through an employer, the Health Insurance Marketplace, or an individual health insurance plan, the new rules will:

  • Ban surprise medical bills for emergency services, even if they are received out-of-network and without a prior authorization.
  • Ban out-of-network coinsurance or copayments for all emergency and some non-emergency services. The patient will not be charged more than the in-network costs for these specific services.
  • Ban out-of-network charges and surprise bills for supplemental services (like anesthesiology or radiology) by out-of-network providers who are rendering the services at an in-network facility.

If a patient does not have health insurance or chooses to pay their medical expenses without using health insurance (self-pay), these new rules require that the health care provider or facility rendering services provide the patient with a “good faith” estimate of how much the charges will be for an item or service. In addition, providers and facilities must:

  • Provide the patient with the good faith estimate before a service is scheduled, within certain timeframes.
  • Offer an itemized list of each charge or services, grouped by the provider or facility, and include a detailed description or itemized code with the expected charges.
  • Provide an explanation of the good-faith estimate upon patient’s request, and follow up with a paper or electronic copy of the estimate.
  • Provide a good-faith estimate in a way that is accessible to the patient.

If a patient is billed over $400 more than the good-faith estimate provided when the service was scheduled, they may utilize a new patient-provider dispute resolution process to determine a payment amount. This process is done by a third-party arbitrator. A patient may use this process only if they meet the following requirements:

  • The patient is uninsured, or self-pay.
  • The patient was given a good-faith estimate from the provider or facility who rendered the service.
  • The patient received a bill within the last 120 calendar days.
  • The difference between the good-faith estimate and the bill is at least $400.

Some providers can ask the patient to waive their rights voluntarily. This may be done by prior written consent from the patient but is never allowed for emergency services or certain other non-emergency services covered by the NSA. Notice and Consent Waiver is not permitted for the following:

  • Emergency services.
  • Urgent medical needs arising when non-emergent care is being given.
  • Ancillary services, including items or services related to emergency medicine.
  • Items and services provided by assistant hospitalist, internists, etc.
  • Diagnostic services including radiology and lab services.
  • Items and services provided by an out-of-network provider if there is not another in-network provider option available to provide that service in that facility.

The regulation defines “facilities” to include hospitals, hospital outpatient departments, and ambulatory surgery centers. Consumers currently do not have federal protections against surprise bills for nonemergency services provided in other facilities such as clinics, nursing homes, or urgent care centers. Patients seeking services or care at such facilities may want to inquire about whether providers bill independently and/ or are in network.

Pure Healthcare Compliance Department
4179 S Riverboat Road, Suite 203
Taylorsville UT  84123

Compliance Hotline
Phone:(801) 823-0120
Email: compliance@montanaarthritis.com