1. Emergency Services.

The NSA prohibits surprise charges for emergency services, even if they are provided by an out-of-network provider or at an out-of-network facility. Insurance companies are required to cover these services without prior authorization, and payments must match the costs that would be charged for in-network services, including copayments, coinsurance, and deductibles. Prior authorization is not required for emergency care, and insurers cannot delay or deny payments based on plan status.

2. Non-Emergency Services at In-Network Facilities.

If a patient receives non-emergency services at an in-network facility but is unknowingly treated by an out-of-network provider (such as a radiologist), the provider cannot charge more than the in-network cost-sharing amount. This prevents balance billing in situations where patients have little control over which providers treat them.

3. Air Ambulance Services.

The NSA also extends protections to air ambulance services, preventing patients from facing unexpected charges for out-of-network air ambulance care. Patients are only responsible for amounts consistent with what would be charged by their health plans. However, ground ambulance services are not yet included, although this issue is currently being studied for future regulations.

4. Good Faith Estimates for Uninsured/Self-Pay Patients.

Providers are required to give uninsured or self-pay patients a good faith estimate of the expected charges for medical services in advance. If the actual charges significantly exceed the estimate, patients can dispute the bill through a newly established patient-provider dispute resolution process.

5. Independent Dispute Resolution (IDR).

If disputes arise between health plans and out-of-network providers over payment amounts (when surprise billing protections apply), an IDR process can be used. Both parties submit payment offers, and an arbitrator selects an offer based on several criteria. The losing party is responsible for the arbitration costs.

6. Prior Notice and Consent Process.

For certain non-emergency services, out-of-network providers may still balance bill patients, but only if they provide advance notice (at least 72 hours prior, or 3 hours before a same-day service) and obtain the patient’s written consent. However, this process cannot be used for certain services, such as emergency care, anesthesiology, radiology, pathology, neonatology, diagnostic services, or hospital, intensive care, and surgical services, where protections against surprise billing still apply.

7. Health Plan Transparency.

Insurance companies must provide clear and detailed explanations of benefits after receiving care, including how much they will pay for services, what services are out-of-network, what the plan will cover, and what patients can expect to pay. This helps patients better understand their medical bills and avoid unexpected charges.

8. Protections Beyond State Borders.

The NSA extends protections across state lines by covering federally regulated health plans, even in states that do not have surprise billing laws or where state laws are less comprehensive.

9. Public Reports and Applicability.

The NSA requires federal agencies like the Department of Health and Human Services (HHS) to report the outcomes of IDR cases and other enforcement actions, helping to set precedents and prevent new surprise billing disputes. The HHS is also responsible for overseeing the implementation and enforcement of NSA protections.

1. Huge Volume of Disputes.

The NSA’s Independent Dispute Resolution (IDR) process, designed to resolve disputes between insurers and out-of-network providers, has been overwhelmed with far more cases than anticipated. Initially, regulators estimated around 17,000 disputes annually; however, the first year saw over 330,000 disputes registered. This surge has resulted in long delays in resolving claims and delayed payments to providers.

2. Complexity of Eligibility for Dispute Resolution.

Determining whether a claim is eligible for the federal IDR process is complicated. Many disputes involve challenges related to state versus federal jurisdiction, as the NSA defers to state laws where they exist. This has led to confusion and delays in processing disputes.

3. Confusion among Providers and Patients.

Many healthcare providers and patients struggle to understand the specific protections and procedures under the NSA, particularly the rules regarding notification and consent for out-of-network billing. Communication failures can lead to compliance issues, undermining the law's effectiveness.

4. Administrative Burden for Providers.

The dispute resolution process under the NSA adds administrative complexity for healthcare providers, requiring substantial resources to navigate the IDR system. Smaller providers, in particular, may encounter significant difficulties in meeting procedural requirements.

5. Long Wait Times for Dispute Resolution.

Delays in the IDR process create prolonged uncertainty for providers regarding payment. This can cause financial strain and slow down the revenue cycle, particularly for smaller providers and emergency service providers.

6. Conflicts Between State and Federal Laws.

In states with existing laws against surprise billing, conflicts between state regulations and the NSA can create additional confusion regarding which rules apply. This complicates compliance for both providers and insurers.