Understanding the Surprise Billing Act: What Insurers and Providers Need to Know

Table of Contents

• Key Provisions of the Surprise Billing Act
• Impact on Insurers
• Impact on Providers
• Role of FHAS in Dispute Resolution
• How the Dispute Resolution Process Works
• Best Practices for Insurers and Providers

Since its passage in 2022, insurers and providers are continuing to learn and implement the provisions of the Surprise Billing Act. While the act aims to protect patients from unexpected medical bills, it also introduces new requirements and challenges for healthcare professionals.

As a certified Independent Dispute Resolution Entity (IDRE), FHAS specializes in the IDR Process, resolving payment disputes between healthcare providers and health insurance plans for out-of-network services.

Whether you’re dealing with changes in billing practices, adjusting to new reimbursement processes, or seeking strategies for compliance, we’re here to help. Here’s what you need to know about the Surprise Billing Act and its implications for your practice or business.

Key Provisions of the Surprise Billing Act

The Surprise Billing Act includes several important provisions that healthcare professionals need to understand and implement effectively:

• Prohibition of Balance Billing in Emergency Situations: Patients cannot be billed for more than their in-network cost-sharing amounts in emergencies, even if the provider is out-of-network.
• Rules for Non-Emergency Services at In-Network Facilities by Out-of-Network Providers: The act sets guidelines to prevent out-of-network providers from charging patients more than the in-network rates at in-network facilities.
• Patient Cost-Sharing Protections: Patients are protected from higher cost-sharing amounts for emergency and certain non-emergency services by out-of-network providers.
• Notice and Consent Requirements for Out-of-Network Services: Providers must give patients notice and obtain consent for out-of-network care, detailing the potential out-of-pocket costs.

Now, let’s look deeper at the implications for each group.

Impact on Insurers

The following are some significant changes for insurers that require careful attention and adaptation::

• Changes in Reimbursement Processes: Insurers must adjust their reimbursement procedures to align with the new rules. This ensures that out-of-network services are reimbursed at the appropriate rates mandated by the act.
• Requirements for Updating Network Directories: Insurers are now obligated to maintain accurate and up-to-date network directories. These directories must provide clear information about in-network and out-of-network providers to help patients make informed decisions.
• Implications for Contracting with Providers: The act affects how insurers negotiate contracts with providers. It emphasizes the importance of transparent and fair agreements to avoid surprise billing situations.
• Compliance Challenges and Strategies: Insurers face new compliance challenges under the act, including the need to update their internal systems and procedures to meet regulatory standards. Developing comprehensive staff training and robust monitoring systems can help ensure compliance and avoid penalties.

Insurers who understand and address these impacts can better navigate the new rules. 

Impact on Providers

Providers have to adapt too as they comply with new regulatory standards. Here are some things to think about:

• Adjustments in Billing Practices: Providers must make adjustments to their billing practices to adhere to the new regulations. This includes ensuring transparency in billing and complying with the act’s provisions on balance billing.
• Coordination with In-Network Facilities: Providers need to enhance coordination with in-network facilities to avoid unintentional out-of-network services. This involves clear communication and adherence to network agreements.
• Impact on Out-of-Network Services and Negotiations: The act affects how providers handle out-of-network services and negotiate reimbursement rates. It emphasizes fair billing practices and requires providers to inform patients about potential out-of-pocket costs.
• Compliance Requirements and Documentation: Providers face new compliance requirements, including documentation of consent for out-of-network services and adherence to billing transparency standards. These requirements aim to protect patients from surprise medical bills and ensure clarity in billing practices.

By using these strategies and keeping up with regulatory updates, providers can reduce risks and keep their operations running smoothly.

Role of FHAS in Dispute Resolution

As a certified Independent Dispute Resolution Entity (IDRE) under the No Surprises Act, FHAS resolves payment disputes between healthcare providers and health insurance plans for out-of-network services. Here’s how FHAS ensures fair and efficient resolution:

• Overview of FHAS’ Certification as an IDRE: FHAS is certified to impartially resolve disputes under the No Surprises Act, in compliance with regulatory standards.
• Importance of Impartial and Efficient Resolution: FHAS prioritizes fair outcomes through a transparent process, facilitating timely resolutions that benefit both providers and insurers.
• Description of FHAS’ Fair and Transparent Process: FHAS employs streamlined processes to handle disputes, maintaining transparency and fairness in every resolution.
• Experience and Qualifications of FHAS Professionals: FHAS’s team includes experienced arbitrators with decades of healthcare adjudication expertise and training from the American Health Law Association. Their expertise ensures accurate and industry-standard resolutions.

FHAS is dedicated to making dispute resolution in healthcare billing more effective and fair. We help both providers and insurers handle the challenges of out-of-network payment disagreements. For more information about the benefits of arbitration, see:

Insurance Dispute Resolution: The Benefits Of Arbitration

How the IDR Process Works

At FHAS, our independent  dispute resolution (IDR) process ensures fairness and clarity in resolving payment disputes under the No Surprises Act. Disputes are initiated through the CMS Portal, where parties select an IDRE or have one assigned if they cannot agree within three days. 

At that point, both parties receive notification, and if FHAS receives the dispute for resolution here’s how we manage it:

• Equal Opportunity for Both Parties: FHAS ensures that both parties have equal opportunity to present their cases. We maintain transparency throughout the process to facilitate a fair resolution.
• Criteria Used for Binding Decisions: Decisions are based on criteria set forth in regulatory guidelines and the No Surprises Act. We consider all submitted documentation and relevant factors to reach a binding resolution.
• Benefits of FHAS’ Expertise and Training: FHAS’ team includes professionals with extensive experience and training through the American Health Law Association. This expertise ensures accurate adjudication and compliance with industry standards.

Our streamlined process and commitment to fairness make FHAS a trusted partner in navigating the complexities of healthcare billing disputes. For more about how to select an IDRE, see:

How To Choose An Impartial IDRE: A Guide For Providers And Payers

Best Practices for Insurers and Providers

There are some important steps for both insurers and providers to be in compliance. Here are the fundamentals:

• What Insurers Can Do: Insurers should regularly update their reimbursement processes to align with new regulatory standards. Maintaining accurate network directories and transparent communication with providers can help avoid billing discrepancies.
• What Providers Can Do: Providers must update their billing practices to comply with the act’s provisions, and show transparency and fairness to patients. Coordinating effectively with in-network facilities and understanding what the contractual obligations are with insurers can mitigate billing disputes.
• Communication and Coordination Important for Insurers and Providers: Good communication between insurers and providers clarifies billing expectations and resolves disputes sooner. With coordination, both parties are aligned on billing practices and compliant with regulatory requirements.
• Role of FHAS in Facilitating Smooth Dispute Resolution: FHAS is a neutral IDRE to facilitate efficient resolution of payment disputes between insurers and providers. With a transparent process and clear line of communication, FHAS helps providers and payers avoid common pitfalls and streamlines dispute resolution in compliance with the IDR Process No Surprises Act. For some of the common mistakes made in dispute resolution, see: Where Providers And Health Plans Go Wrong In Filing IDR Disputes

Partner with FHAS for Expert Guidance

Reach out to FHAS today to learn more about how we can help you navigate the shifting terrain of healthcare billing to get a fair outcome for all parties. FHAS renders timely payment determinations, over 100,000 in the past year.Together, we can foster transparency, compliance, and trust in healthcare billing practices.