Big surprises in the No Surprises Act | McAfee and Taft

In one of the federal government’s biggest attempts to combat surprise medical billing, Congress passed the No Surprises Act (NSA) in late 2020, which imposes a host of new transparency and coverage requirements for health plans. employer-sponsored group health. Many of the most significant coverage changes were scheduled to be implemented on January 1, 2022, for most plans.

There are two main surprise billing situations regulated by the NSA. With the first, a participant goes to a facility in the network, but one of the treating providers, such as the anesthetist, is out of the network. After the NSA, participants are only liable for in-network cost-sharing amounts (co-pay, coinsurance) to the out-of-network provider, and the payments count towards the in-network deductible. An exception exists for certain “non-ancillary services” in which, only after the participant has been notified and consented to the out-of-network prize, he or she may receive a balance bill.

Second, although not a completely new requirement, group health plans must impose in-network cost sharing when plan members travel to an out-of-network emergency room for services. emergency. Although this has been the rule for emergency rooms connected to a hospital since the Affordable Care Act, the NSA extends these requirements to independent, self-contained emergency rooms if they are licensed as such by the state.

When in-network cost-share rates are required for an out-of-network provider, the cost-share is usually based on the “eligible payment amount” (QPA) and not the amount actually charged. The QPA is a complex formula – basically the average rate in the network for the plan or its third-party administrator.

However, the APQ only determines the amount that the participant must pay. For the plan’s share of the bill, the NSA is imposing a new mandatory Independent Dispute Resolution (IDR) process. If the provider and the plan are unable to agree on a price for the service through voluntary negotiations, either party may initiate the IDR process. A government-approved IDR entity arbitrates the dispute. Both parties submit evidence and a price that each believes is the appropriate payment. The IDR entity is then required to choose one of the payment proposals, usually the one that comes closest to the QPA.

Remember: Employers should work with their health plan service providers to ensure that these requirements have been operationally implemented in a timely manner and that the plan document will be amended accordingly.

This article originally appeared in the January 13, 2022 issue of Log recording. It is reproduced with the permission of the publisher. © The Journal Record Publishing Co.

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