Debate Continues Over Implementation of NSA Provisions

By now, most of you are surely familiar with the No Surprises Act (NSA), a federal law that protects patients from unexpected medical bills. The Act and its subsequent regulations protect insured patients from getting balance-billed in a number of circumstances, including emergencies.  

However, notably, the Act does not include protections for a very common – and expensive – emergency service: that is, when a patient needs a ground ambulance.  

Instead, Congress basically set aside ambulance balance billing as an issue that needed to be studied more before policymakers developed laws for it.  

To that end, Congress set up the Ground Ambulance & Patient Billing Advisory Committee, comprised of commercial and governmental stakeholders.

Just last week, the Committee came out with a set of recommendations on air ambulance reimbursement.

• First, the Committee suggested that there be a $100 cap on what a patient should have to pay for an ambulance.

• Second, the Committee suggested Congress apply the same relationship between federal law and state laws that currently exists in the NSA; that is, any future federal law should only apply if there is no state law on out-of-network ambulance reimbursement.  

Now, on the one hand, this makes a lot of sense, as nearly 20 states have adopted laws that apply to ambulance reimbursement.

On the other hand, this makes a complex issue even more complex, especially for health plans that work across multiple states.

Either way, Congress has no plans to pass a law on ambulance reimbursement in the near future.

Another element of the No Surprises Act that was set aside for more consideration was the requirement that providers and payers give patients an estimate on costs before medical services are provided. The NSA called these estimates an advanced explanation of benefits – or AEOB.

Providers are currently required to present advanced cost estimates directly to uninsured or self-pay patients.

However, under the NSA, providers were also required to send good-faith estimates to a patient’s health plan if they were insured, and the health plan was then required to send the member an AEOB explaining member costs.

Like ambulance reimbursement, the government basically put off publishing requirements for the AEOB until it had a chance to think through the issue.

This summer, the government announced it would publish a proposed rule on the AEOB next March. One of the outstanding questions is whether the rule would require providers to send health plans diagnosis codes as part of the advanced good-faith estimates; after all, in some cases, a doctor may not have even seen a patient who is requesting specific medical care, so how is that doctor supposed to send diagnosis codes as part of an advanced price estimation?

Another question is how providers will be expected to send or submit these good-faith estimates to payers. For example, will the government require certain standard electronic formats to be used?

If that’s not enough, the government also expects to publish a new NSA regulation this November that would change nearly every aspect of the Independent Dispute Resolution (IDR) process that providers now access when they disagree with how they were paid for No Surprises Act claims.

Between new expected regulations and ongoing litigation, we expect another busy year in the ever-evolving requirements of the No Surprises Act.