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Coming Soon: New Rules for Surprise Billing 

by | Jun 15, 2021

Healthcare providers nationwide should take note of significant new rules coming into effect regarding surprise billing. Here’s an overview of what’s important to know. 

What is Surprise Billing? 

Surprise billing occurs when an insured patient unknowingly receives care from a provider who is out of their insurance network — and is then presented with a bill and payment obligation beyond what the patient’s insurance will cover. Surprise medical bills can arise in many healthcare situations but are most often associated with emergency care. In an emergency, a patient typically does not have the ability to choose the provider rendering services to ensure they are in-network. Surprise bills can also occur during planned care at an in-network facility, and are usually associated with providers the patient does not interface with directly, such as pathologists and radiologists. 

Why are Changes Coming? 

New surprise billing regulations were included in the Consolidated Appropriations Act (CAA) of 2021. The CAA was signed into law on December 27, 2020. 

What is Changing? 

Under the new law, plans and providers (including hospitals, facilities, individual practitioners, and air ambulance providers) may not – under certain circumstances – bill patients more than in-network cost-sharing amounts. This applies to both emergency and non-emergency situations in which patients do not have the ability to choose an in-network provider. The US Department of Health and Human Services is working to develop regulations to implement the final law, but as of May 2021, they have not been released. 

That being said, understanding certain key terms in the legislation will help your organization navigate the changes when they are finalized: 

  • Notice of consent: For non-emergency services, if providers meet notice and consent requirements, they may balance bill patients. 
  • Covered services: This law covers emergency services, air ambulances, and non-emergency services at an in-network facility performed by an out-of-network provider. 
  • Patient responsibility: In situations covered by this law, the patient is only responsible for the cost-sharing amount that would be billed had services been considered in-network. The patients cannot be balance billed under these circumstances.

When Do These Changes Take Effect? 

These changes will take effect starting January 1, 2022. 

How Will Surprise Billing Impact My Practice? 

Going forward, it will be critical for practices to ensure that they do not collect patient balances that – underneath the new regulations – cannot be collected by law. Practices must also make sure consent forms are created to accommodate for non-emergency services. With the regulations set to go into effect in 2022, now is the time to get organized. 

Medical Advantage Can Help 

If you need assistance understanding these new rules or would like help accounting for these new rules in your EHR, please contact Medical Advantage at info@medicaladvantage.com or 800.594.6115. 


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