Enacted at the end of 2020, the federal No Surprises Act (NSA) prohibits certain health care providers and facilities that provide their services outside of health plan provider networks from “balance billing.” As a result, those providers and facilities cannot hold patients responsible for the difference between what the provider or facility charges and what health plans or other third-party payers pay for the services.

Recent court decisions have put the rules for determining how much health plans and insurance companies pay those out-of-network providers who are prohibited from balance billing under the new law in flux, further complicating the already complex system for paying health claims. Because providers continue to file lawsuits challenging portions of the federal regulations governing these provider payments, it is unlikely that providers or payers will have a satisfactory or predictable process in place for determining out-of-network payment rates anytime soon.

There are three types of out-of-network health care services covered by the NSA’s balance billing prohibitions: emergency services, air ambulance services, and certain services provided to patients on an out-of-network basis within an in-network facility, such radiology or anesthesiology services from out-of-network providers within an in-network hospital. The NSA directs how payments to out-of-network providers rendering these services will be determined, and the U.S. Departments of Health and Human Services, Labor, and Treasury have issued regulations and related guidance for making those payment determinations.

Complete your profile to continue reading and get FREE access to BenefitsPRO.com, part of your ALM digital membership.

Your access to unlimited BenefitsPRO.com content isn’t changing.
Once you are an ALM digital member, you’ll receive:

  • Critical BenefitsPRO.com information including cutting edge post-reform success strategies, access to educational webcasts and videos, resources from industry leaders, and informative Newsletters.
  • Exclusive discounts on ALM, BenefitsPRO magazine and BenefitsPRO.com events.
  • Access to other award-winning ALM websites including ThinkAdvisor.com and Law.com

Already have an account?



Join BenefitsPRO

Don’t miss crucial news and insights you need to navigate the shifting employee benefits industry. Join BenefitsPRO.com now!

  • Unlimited access to BenefitsPRO.com - your roadmap to thriving in a disrupted environment
  • Access to other award-winning ALM websites including ThinkAdvisor.com and Law.com
  • Exclusive discounts on BenefitsPRO.com and ALM events.

Already have an account? Sign In Now
Join BenefitsPRO

Copyright © 2023 ALM Global, LLC. All Rights Reserved.