Federal Surprise Billing Prohibition Is Now in Effect! Be Sure You Are Compliant

January 5, 2022

Changes are now in effect at the federal level to protect patients from surprise bills for medical services. As of Jan. 1, 2022, the No Surprises Act* directs that out-of-network physicians (who provide care at in-network facilities) may not bill patients for any amount beyond the patient’s in-network cost sharing obligation.

The AMA offers a Toolkit for Physicians: Preparing for Implementation of the No Surprises Act. The toolkit is divided into three parts, focusing on operational challenges that physicians need to address immediately to be compliant with the new requirements:

• Part I: Non-emergency services at in-network facilities
• Part II: Emergency services and post-stabilization care at hospitals or freestanding emergency departments
• Part III: Good faith estimates (GFEs) for self-pay and uninsured patients

Be sure to access AMA’s comprehensive free Toolkit!

Here in Illinois

Since 2013, patients who are insured by a health plan regulated by the Illinois Department of Insurance have had some protection against surprise billing. Certain types of facility-based physicians (radiologists, anesthesiologists, pathologists, emergency physicians, and neonatologists) have been prohibited from balance billing out-of-network patients who receive care at in-network facilities.

The new federal law extends this prohibition to all non-participating facility-based physicians providing services at an in-network hospital or other facility, and applies to group-sponsored health plans, as well as those regulated by the state. The No Surprises Act also includes new patient notification requirements and mandates that physicians provide good faith estimates to some patients prior to delivering services.

Even though rules are now in place for some aspects of the federal law, other implementation guidance is still being developed, including details related to the interaction between the state and federal law. However, it is clear that facility-based physicians may not balance bill patients when the facility is in the patient's health insurance network.p

If you have questions, please contact the ISMS Health Policy Research and Advocacy team by email.

*The No Surprises Act applies to employer-sponsored group health plans (those generally regulated by ERISA and exempt from state-level insurance regulations) and individual plans purchased through the health insurance exchanges or on the individual market. The Act does not apply to Medicare and Medicaid, which already have protections against surprise billing.