Surprise Billing Protections Take Effect in 2022

A painstakingly negotiated and long-awaited fix to the “surprise billing” issue is finally set to take effect on January 1, 2022. The No Surprises Act, passed as part of a larger funding package in late 2020, seeks to tackle the issue of patients receiving large, out-of-network bills when they have little or no option of seeing an in-network provider.

The act specifically targets instances when patients visit an in-network hospital or facility, but are treated by out-of-network providers (anesthesiologists, ER doctors, etc.) whom they can not choose. Second, it looks to protect patients treated at out-of-network hospitals in emergency situations. Finally, it targets out-of-network air-ambulance rides (ground ambulances are excluded from the act). The law covers virtually all private health insurance plans, including those provided by an employer as well as individual plans purchased on or off the government marketplace exchanges. Key provisions from the final rule include:

  • Out-of-network emergency services must be covered with patient balances limited to in-network cost-sharing amounts (no balance billing of adjusted charges)

  • Out-of-network ancillary services at an in-network facility must be covered with patient balances limited to in-network cost-sharing amounts

  • Rates will be set using insurances’ Qualified Payment Amount (QPA), which they will calculate based on median in-network rates

  • In most instances, if providers do not agree with their initial payment, they can enter a 30-day negotiation period with insurances

  • If no agreement is made during the 30-day period, providers can request an independent dispute resolution (IDR), a binding, arbitration-like process, to settle the rate

  • To bill a patient for out-of-network charges, providers must notify them at least 72 hours prior to the service of their network status, provide a “good faith” estimate of their likely bill, and receive written consent

  • Providers and facilities must post public disclosures detailing the No Surprises Act in their offices and on their websites


For further details, review the AMA’s summary of the No Surprises Act click here:

Brandon McCurdy