No Surprises Act prohibits balance billing, creates arbitrat

No Surprises Act prohibits balance billing, creates arbitration process for out-of-network providers | Hogan Lovells


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Effective January 1, 2022, the “No Surprises Act” signed into U.S. law as part of H.R. 133, “Consolidated Appropriations Act, 2021,” implicates (1) emergency services provided by non-participating providers at participating facilities; (2) non-emergency services performed by non-participating providers during a visit at certain participating facilities; and (3) air ambulance services. The law establishes maximum patient out-of-pocket amounts, which generally cannot be more than the amount that would have been charged to the patient had the services been provided by a participating provider or facility. It also prohibits balance billing, but creates an advance beneficiary notice (ABN)-like process applicable to services furnished by non-participating providers at participating facilities to permit providers to balance bill under certain circumstances. Additionally, the law establishes an Independent Dispute Resolution (IDR) process for plans and providers to negotiate the rate that will be paid to the non-participating provider or facility if the parties cannot agree.

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