No Surprises Act

Many provisions of the No Surprises Act take effect in 2022. The Frequently Asked Questions and Vignettes below provide an overview for physicians on the No Surprises Act.

Frequently Asked Questions

What is the No Surprises Act?

The No Surprises Act, part of the 2021 Consolidated Appropriations Act, was enacted to protect patients from unexpected medical bills for care received out-of-network (sometimes referred to as balance billing) while also requiring that uninsured or self-pay patients receive information about expected costs of services in advance. The No Surprises Act creates a floor for protecting patients from surprise bills and defers to state laws on surprise billing, where applicable. See the AMA's summary of the No Surprises Act, the CMS fact sheet, and the AMA No Surprises Act toolkit for more information and resources.

Who does the No Surprises Act apply to?

The No Surprises Act applies to out-of-network providers providing emergency services at hospitals or freestanding emergency departments; out-of-network providers providing non-emergency services at hospitals, hospital outpatient departments, or ambulatory surgery centers; and providers providing care to uninsured or self-pay patients.

What changes are required for all providers?

All providers must provide a good faith estimate (GFE) of charges to uninsured or self-pay patients. The GFE provides information on anticipated costs for services. See HHS FAQs on GFEs and HHS template GFE. Practices must post notice of the availability of the GFE in the office and on their website. Additionally, all providers must provide any updates to their information for health plan provider directories.

How do we provide a GFE without knowing how complicated the visit will be ahead of time?

A GFE should include, among other requirements, an itemized list of services reasonably expected to be furnished for or in conjunction with the primary item or service. After services are provided, if the actual charges exceed the original GFE by $400 or more, the patient can dispute the bill.

Vignettes

Vignette #1 – Self-pay Patient

A 16-year old patient schedules an appointment for advice on birth control and states that she wants to pay cash for the visit rather than bill her insurance so that her parents do not find out. This is within the legal jurisdictional guidance.

How does the No Surprises Act apply?

Even though this patient has insurance, she would be considered a self-pay patient since she does not plan to submit the claim to her insurance plan. Therefore, the practice must provide a written GFE to the patient.

Vignette #2 – Out-of-network in Office Setting

Your practice terminated your contract with insurance XYZ. A family with insurance XYZ chooses to continue their care with your office using out-of-network benefits. The family schedules an appointment for a well-visit for their child and plans to submit the claim to their insurance.

How does the No Surprises Act apply?

Since the well-visit will take place in the office setting (not within a hospital outpatient department), the No Surprises Act does not require any changes at this time for individuals who are seeking to submit a claim to their plan.