Primer on Provider Requirements under the No Surprises Act (Part II)

This is the second installment in a two-part series regarding the No Surprises Act, which establishes new requirements that will apply to certain healthcare providers and facilities, and providers of air ambulance services. These requirements generally apply to items and services provided to individuals enrolled in group health plans, group or individual health insurance coverage, and Federal Employees Health Benefit plans. Please see our previous post for more information on these requirements.

Below is an overview of the remaining provider and facility requirements that will become effective on January 1, 2022:

• No balance billing for air ambulance services by non-participating air ambulance providers: Providers of air ambulance services will generally be prohibited from billing or holding liable beneficiaries, enrollees, or participants in group health plans or group or individual health insurance coverage who received covered air ambulance services from a non-participating air ambulance provider for a payment amount greater than the in-network cost-sharing requirement for such services.
• Provide good faith estimate in advance of scheduled services, or upon request: A healthcare provider or facility will generally be required to inquire within a specific timeframe outlined in regulation and guidance whether an individual who schedules an item or service is enrolled in a group health plan, group or individual health insurance coverage offered by a health insurance issuer, a Federal health care program, or a Federal Employees Health Benefit plan. If so, the provider or facility must inquire if an individual enrolled in a group health plan, group or individual health insurance coverage offered by a health insurance issuer, or a Federal Employees Health Benefit plan is seeking to have their claims for such item or service submitted to plan. The provider or facility must provide notification (in clear and understandable language) of the good faith estimate of the expected charges, expected service, and diagnostic codes of scheduled services.
• Ensure continuity of care when a provider’s network status changes: A healthcare provider or facility that ends a contractual relationship with a plan or issuer and has a continuing care patient must: (i) accept payment from the plan or issuer (and cost-sharing payments) for a continuing care patient at the previously agreed to payment amount for up to 90 days after the date on which the patient was notified of the change in the provider’s network status and (ii) continue to adhere to all policies, procedures, and quality standards imposed by the plan or issue for such items or services as if the contract were still in place. Generally, this applies in cases where the contractual relationship between a plan or issuer and a provider or facility ends, resulting in a change in the provider or facility’s network status with the plan.
• Improve provider directories and reimburse enrollees for errors: Any healthcare provider or facility that has or has had a contractual relationship with a plan or issuer to provide items or services under such plan or insurance coverage will be required to: (i) submit certain minimum provider directory information to a plan or issuer and (ii) reimburse enrollees who relied on an incorrect provider directory and paid a provider bill in excess of the in-network cost-sharing amount.

For over 35 years, Wachler & Associates has represented healthcare providers and suppliers nationwide in a variety of health law matters. If you or your healthcare entity has any questions pertaining to the No Surprises Act or healthcare compliance, please contact an experienced healthcare attorney at 248-544-0888 or wapc@wachler.com.