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No Surprises Act

Overview of the No Surprises Act’s prohibition on balance billing for non-emergency services

-Generally, out-of-network providers are banned from balance billing an individual who gets covered, non-emergency services that are part of a visit to an in-network health care facility.

Scope of providers that must comply with the No Surprises Act’s prohibition on balance billing for non-emergency services

-The following types of providers are banned from balance billing when providing non-emergency services as an out-of-network provider at an in-network health care facility:

  • Physicians;
  • Other health care providers acting within their scope of practice under applicable State law (e.g., a certified nurse practitioner or physician assistant).

Scope of facilities that can be in-network facilities

-The No Surprises Act’s prohibitions on balance billing for non-emergency services only apply to covered non-emergency services that are furnished as part of a visit to one of the following in-network health care facilities:

  • Hospitals (including critical access hospitals);
  • Hospital outpatient departments; or
  • Ambulatory surgical centers. Reminder: To be considered an in-network health care facility, a facility must be:
  • In-network; or
  • Have a single case agreement with a health plan or issuer for a specific individual.

Non-emergency services for which individuals may never be balance billed

-Ancillary services, which individuals typically have little control over, are ALWAYS subject to balance billing prohibitions.

The No Surprises Act defines ancillary services as:

  • Items and services related to emergency medicine, anesthesiology, pathology, radiology,

and neonatology, provided by either a physician or non-physician practitioner;

  • Items and services provided by assistant surgeons, hospitalists, and intensivists;
  • Diagnostic services, including radiology and laboratory services; and
  • Items and services are provided by an out-of-network provider when there is no in-network provider who can provide the item or service at the in-network health care facility.

Providers and facilities may NEVER seek an individual’s consent to waive the No Surprises Act’s balance billing protections for non-emergency ancillary services through the use of notice-and-consent exceptions.

Notice-and-consent exceptions also NEVER apply to waive the No Surprises Act’s balance billing protections related to non-emergency services when:

  • Items or services are provided due to unforeseen urgent medical needs in the course of care delivery; or are Banned by state laws.

Practice Website Notice

NO SURPRISES ACT

Notice of Good Faith Estimate.

Under the No Surprises Act, you have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost. By law, health care providers and health care facilities are required to give patients who do not have insurance or are not using insurance an estimate of the bill for medical items and services.

  • You have the right to receive a “Good Faith Estimate” for the total expected cost of any non-emergency items or services. This includes related costs such as medical tests and services, medications, and equipment.
  • Orthopaedic Associates will provide you with a Good Faith Estimate as your health care provider in writing. You can also ask our team for a Good Faith Estimate before scheduling an item or service.
  • If you receive a bill at least $400 more than your Good Faith Estimate, you can dispute the bill.
  • Make sure you save a copy or take a picture of your Good Faith Estimate.

For questions or more information about your rights to a Good Faith Estimate or understanding your rights against surprise medical bills, visit www.cms.gov/nosurprises or call the Help Desk at 1-800-985-3059.