HAP Radiology Billing and Coding Blog

The No Surprises Act (NSA) was designed to protect patients from receiving large medical bills from a physician or facility that does not participate in their insurance plan. It was to provide a mechanism whereby the providers could receive a payment from insurers that reflects a reasonable market price, with a dispute resolution process to be used when the parties were too far apart to reach an agreement. While this all sounds very reasonable and good for patients, it always seemed like the insurance companies could use the law as leverage to terminate existing agreements with providers who had negotiated high fee schedules and force them into lower-rate contracts. And that is exactly what is beginning to happen.

Keeping abreast of the various healthcare rules and regulations from federal and state authorities can sometimes be overwhelming for a practice’s management. Here is a summary of some of the most important regulatory issues to be aware of for next year, along with a few payment policy decisions that are not governmental. The links will take you to our recent articles and other sources that probe each topic in more depth.

On January 1, 2022, practices will have to comply with the federal No Surprises Act (NSA) unless their state has a similar law already in effect. The federal legislation that was passed in December 2020 is intended to allow providers to receive a reasonable payment from insurers for services to non-network patients without putting those patients in the middle of a payment dispute. At the end of September, long-awaited regulations that will govern the details of its implementation were issued and were met with displeasure by healthcare providers. For example, the American College of Radiology^® (ACR^®) wrote in its detailed summary of the rule that it “is disappointed that the regulations violate the intent of the No Surprises Act (NSA) by making the Qualified Payment Amount (QPA) the primary determinant of physician payment rates in the independent dispute resolution process.”

The No Surprises Act* will become effective January 1, 2022. This is the first federal regulation that is aimed at protecting patients from receiving unexpected bills from healthcare providers who are outside of their insurer’s network. Review our recent article for an overview of its provisions.

The issue of patients receiving large, unexpected medical bills from hospitals and physicians has been widely publicized. This situation, known as surprise billing, arises when a hospital or physician provides medical care to a patient but is not participating in a patient’s insurance network. We have reported on the many states that have put legislation in place to try and mitigate the problem for their own residents, but now there will be a nationwide policy thanks to recent federal legislation.

The “Consolidated Appropriations Act, 2021” (CAA) is a sweeping piece of legislation that provides relief to individuals and businesses impacted by the COVID-19 public health emergency. Some of the relief provisions apply to all businesses, including medical practices, but it also contains several measures that specifically apply to medical practices.

In the absence of federal regulation, states are adopting laws intended to protect patients from high out-of-pocket costs when they unexpectedly receive services from out-of-network (OON) providers.  When a patient receives an unexpected bill following such OON services the situation is known as “surprise billing.”  Not all OON billing falls into the category of “surprise billing,” however.  In many cases, patients understand that the services they are receiving are OON and they expect to pay all or part of the bill.