What to Expect From the No Surprise Act

Agenda

Introduction to the No Surprises Act

• What Are Balance Bills?
• What Are Surprise Balance Bills?
• What Are the Problems With Balance Bills?
• What Is the No Surprises Act and How Did It Come to Pass?
• When Does the No Surprises Act Go Into Effect?

Which Surprise Balance Bill Situations Are Affected by the No Surprises Act?

• Emergency Services
• Non-Emergent Services Provided by an Out-Of-Network Provider at an In-Network Facility
• Air Ambulance Services
• Everything Else Remains Unaffected
• Ground Ambulance
• NonEmergent OutOfNetwork Services at OutOfNetwork Facilities

How Does the No Surprises Act Affect Surprise Balance Bill Situations?

• In These Situations, Providers Are Precluded From Balance Billing the Patient
• Notice and Consent Exception to the Balance Billing Prohibition
• Initial Health Plan Payments Are Not Regulated and the Current Greatest of Three Rule Will Cease to Exist
• Open Negotiation Period Between Provider and Plan
• If Negotiation Is Not Successful, Provider Can Submit the Dispute to a Baseball-Style Arbitration Process

Baseball-Style Arbitration Process

• Providers Must Act Promptly
• The Provider and Plan Are Required to Make a Final Offer
• The Arbitrator Must Select One of the Final Offers as the Required Payment Amount
• There Are Several Factors the Act Directs Arbitrators to Consider
• Arbitrators May Also Request, or Parties May Provide Additional Relevant Evidence as Long as It Does Not Refer to Certain Categories of Information That the Act Prohibits Arbitrators From Considering
• The Losing Party Pays the Arbitrator's Fee
• Batching of Claims
• Waiting Period

Implementation of the Arbitration Process

• Qualifying Payment Is a Central Factor
• Recent Hospital Pricing Transparency Rule Overlaps
• Who Will Serve as Arbitrators
• Other Uncertainty Left to Subsequent Regulations

Credits

Faculty