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Dawson and Rosenthal
Dawson and Rosenthal

No Surprises Act 2022

We all hear the stories. Individuals go into the hospital for treatment thinking that their bills would be covered because they have insurance, only to receive a surprise bill for thousands of dollars because someone on their care team was not in the health insurance provider’s network.

For a long time, there was not much that individuals could do about this. However, a new federal law that took effect on January 1, 2022, will fix that. The No Surprises Act protects more than 100 million individuals in the United States, and it is important to understand how this law can affect you.

What Does the No Surprises Act Do?

The No Surprises Act (NSA) establishes brand new federal protections against surprise medical bills, and this law has already taken effect. Surprise medical bills arise in a variety of ways, but typically occur when insured consumers receive care from out-of-network hospitals, doctors, and other medical providers that they did not choose.

Studies indicate that this occurs in about one out of every five emergency room visits across the country. Additionally, between 9% and 16% of in-network hospitalizations include surprise bills from out-of-network providers, such as anesthesiologists, radiologists, etc.

Surprise medical bills can place significant financial burdens on consumers when their health insurance plans deny this out-of-network claim or apply higher out-of-network cost-sharing programs.

The NSA will protect consumers from surprise medical bills in a few ways:

  • It will require private health plans to cover out-of-network claims and apply in-network cost-sharing for incoming bills. This law applies to job-based plans as well as non-group plans.
  • It will prohibit hospitals, doctors, and other providers from billing patients more than the in-network cost-sharing amount on surprise medical bills.

The NSA establishes a process for determining payment amounts for surprise, out-of-network bills. This begins with negotiations between plans and providers. If negotiations do not succeed, there will be an independent dispute resolution (IDR) process.

The No Surprises Act applies to most surprise bills, including:

  • Emergency services. The surprise billing protections apply to most emergency service situations, including those provided in hospital ERs, freestanding ERs, and urgent care centers licensed to provide emergency care. This law will also apply to air ambulance transportation, but it does not apply to ground ambulances.
  • Post-emergency stabilization. The NSA has defined emergency services to also include post-stabilization care provided in the hospital following an emergency visit. The post-stabilization care will be considered emergent until a physician determines that the patient can safely travel to an in-network facility using non-medical transport.
  • Non-emergency services at in-network facilities. The NSA also covers non-emergency services provided by out-of-network providers at in-network facilities. Often, doctors and other medical professionals who work inside of a hospital do not actually work for the hospital. They bill independently, and they do not necessarily participate in the same insurance provider network.

Work With an Attorney

If you have received a surprise medical bill and you believe that your insurance carrier is operating in bad faith concerning payment, we encourage you to reach out to a skilled attorney immediately. A bad faith health insurance lawyer in San Diego will have extensive experience handling these claims, and they will work diligently to help ensure that your insurance carrier holds up their end of your policy agreement.