The acronym “NSA” in healthcare stands for the No Surprises Act, a federal law enacted to protect patients from unexpected and often high medical bills. Passed as part of the Consolidated Appropriations Act of 2021, the legislation became effective on January 1, 2022. The primary goal is to shield consumers who have health insurance from receiving “balance bills” when they inadvertently receive services from out-of-network providers. This often occurs when patients have little control over who provides their care.
Identifying Surprise Medical Bills
The No Surprises Act defines situations where balance billing is prohibited, focusing on scenarios where a patient cannot reasonably choose their provider. Protection covers all emergency services, regardless of whether the facility or individual providers are in-network or out-of-network. The law also addresses non-emergency services received at an in-network hospital or ambulatory surgical center. Surprise bills often occurred when a patient chose an in-network facility but was treated by an out-of-network provider working there, such as anesthesiologists or radiologists. The Act prohibits providers from charging the patient the difference between their billed rate and the amount the insurer pays in these circumstances.
Patient Cost Protections
When a situation covered by the No Surprises Act occurs, the patient’s financial responsibility is strictly limited to their in-network cost-sharing, including deductibles, copayments, or coinsurance. The law prohibits the out-of-network provider from billing the patient for any amount above this limit. Furthermore, costs incurred from these surprise services must count toward the patient’s in-network deductible and out-of-pocket maximum. Once the patient pays their limited cost-sharing, they are removed from the payment dispute. The insurer and the out-of-network provider must then resolve the remaining disagreement through Independent Dispute Resolution (IDR), where a third-party arbitrator determines the final payment amount.
The Right to a Good Faith Estimate
The No Surprises Act also includes a provision for price transparency regarding planned care. This requires providers to issue a “Good Faith Estimate” (GFE) to uninsured individuals or patients who choose not to use their insurance (“self-pay” patients). The GFE must be provided before the service is rendered and details the expected charges for the primary service and any related items. Patients have the right to dispute the final bill if the actual charges are substantially higher than the GFE. Specifically, if the final bill is $400 or more above the total estimated amount, the patient can initiate a dispute resolution process.