The new law puts restrictions on balance billing by out-of-network providers. That means having the right member and provider engagement model is key to preventing a blizzard of questions for HR to handle.

The “No Surprises Act” is a federal healthcare law that took effect Jan. 1, 2022. It’s designed to prevent consumers from being surprised by unexpected medical bills after receiving services from an out-of-network (OON) provider.

As with most changes to an already-complex healthcare system, HR teams might be unpleasantly surprised by the confusion and questions this new law could trigger among health plan members and providers.

Because New York and Texas previously adopted similar laws, Quantum Health has experience assisting members and providers with the main coverage and billing provisions. Following are some details benefits professionals should know about the new federal law, along with the scenarios where our Care Coordinators are having the most opportunities to engage, educate and assist members and providers.

Acting To Reduce Out-of-Network Surprises

The No Surprises Act puts billing limits on providers and coverage requirements on health insurers for three types of services:

  • Emergency services. The act requires that a health plan provide coverage even without prior authorization and regardless of whether a facility is in-network (INN) or OON. Also, emergency and urgent care providers can’t “balance bill” for OON charges. Balance billing means a provider is attempting to bill the consumer for the remainder of their fees, beyond an allowed amount paid by the health plan.
  • Nonemergency services by an OON provider at an in-network facility. The act bans OON providers from balance billing for services provided at a facility contracted as INN with the patient’s health plan.
  • Air ambulance. The act blocks providers from balance billing for OON air ambulance services.

The act, still in the process of being finalized with additional provisions, also includes:

  • Providers must take specific steps to communicate the act’s protections to consumers.
  • Providers that dispute the amount they’re being paid have the option to contact the insurance carrier or third-party administrator (TPA) and engage in independent dispute resolution (IDR) process called for in the law.
  • Importantly, OON providers can ask consumers to waive their No Surprises protections. However, a consumer’s consent must be given voluntarily, via a detailed written form, and they can later withdraw consent.

Solving Balance Billing Issues With Members and Providers

Quantum Health acts as the single point of benefits contact for members and their providers, so we’re uniquely positioned to receive and resolve No Surprises questions and issues. Based on our state-level experience, the most common issues with the new federal law will be providers’ attempts to balance bill and whether members have consented to pay for OON charges. Here’s how our Care Coordinators resolve those issues:

  • Member receives a balance bill.
    Few things will upset a member more than a surprise medical bill for what could be thousands of dollars. When they contact us, worried and confused, our Care Coordinators engage the provider to confirm whether the member gave written consent to be billed for OON charges. If the provider does not have that consent, we inform them that they can’t balance bill the member.
  • Provider disputes payment of a claim.
    In the scenario above, and anytime a provider disputes the amount they’re being paid, our Care Coordinators will refer them to the TPA or carrier so they can pursue IDR. That process might result in the provider being paid more, but those fees are paid by the health plan, not the member.

Quantum Health research shows that HR professionals already spend about 25% of their time dealing with benefits-related issues. Without a partner to receive and resolve these types of questions and billing disputes, HR teams will likely see a significant uptick in benefits-related workload related to the new act.

Fortunately, Quantum Health’s clients are supported by an engagement model through which the act can have its intended impact — reducing surprise billings to members — while preventing HR from being inundated by inquiries.

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