No Surprise Act: Impact on Healthcare Provider; Part 3



  1. In-network rates will likely be adjusted to offset the out-of-network impact
    : If providers know they will begin to lose money they historically made from out-of-network billing, they will need to make up for those losses somehow. One way to do this is an incremental increase in in-network rates. This will allow providers to make more off of each in-network patient while also boosting the out-of-network “median.”
    Detail: It will take time for markets, payers, and providers to find a new balance with the limiting of out-of-network billing. MRA makes it possible for providers to understand the rate spread in their market. This will be key for providers positioning themselves in a way that meets the economic needs of the system and is attractive to the payers.
  2. Balance billing is prohibited
    : Out-of-network providers of emergency services will not be allowed to balance bill patients beyond the applicable in-network cost-sharing amount.
    Detail: This is targeted at emergent care, not all Balance bills can still be sent by providers or facilities that provide non-emergency care that is not explicitly covered by the NSA (outpatient mental health providers, for example, or services delivered in a physician’s office, will not be covered).
  3. Out-of-network providers cannot bill for excess charges
    : This is essentially an extra layer of protection for consumers. The law states that providers “shall not bill, and shall not hold patients liable” for an amount that is more than the in-network cost-sharing amount for such services. Without the direct language, out-of-network providers could continue to bill patients for the full amount and only later refund the excess amount when and if a patient learns surprise billing protections apply.
    Detail: This puts the burden on out-of-network providers to know the patient insurance status and the appropriate in-network QPA for the surprise medical bill.
  • Patients can expect to pay what they would pay for the same service if it were provided by a network provider.
  • For the health plan’s reimbursement to the provider, if there is an applicable state-required reimbursement process, the state law takes precedence. If there is no applicable state law, the Act outlines a reimbursement process to follow.
  • Under the Act’s process, a health plan reimburses the provider an initial payment. If the provider does not like the payment amount, the provider has 30 days to negotiate a different amount. If the negotiation fails, then either party may invoke arbitration. After both parties submit a proposed payment, the arbitrator must select one, with no ability to split the difference between the two proposals. The losing party must pay for the arbitration.
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