No Surprises Act Explained

The No Surprises Act Went Into Effect on January 1, 2022.
Approximately 20% of ER Visits and 9%-16% of Hospitalizations Results in a Surprise Out-of-Network Medical Bill to Patients.
The No Surprises Act Requires Health Insurance Companies to Apply Out-of-Network Bills to Member's In-Network Deductible and Co-Insurance.
The No Surprises Act Also Requires Out-of-Network Doctors to Not 'Balance-Bill' Patients for Any Additional Payment.
The No Surprises Act States that Insurance Companies and Providers Must Negotiate a Payment Amount for Out-of-Network Bills Using the Qualifying Payment Amount (QPA) as Guidance.
The QPA is the Medical In-Network Allowed Amount an Insurance Company Pays Providers for a Medical Service in a Particular Geographic Area.
The Texas Medical Association Recently Sued Regarding the QPA and a Federal Judge Sided with them Saying that the QPA Cannot be the Sole Determinant of the Amount Paid by the Insurance Company to the Provider.
Sources:
www.statnews.com/2022/02/23/f...
energycommerce.house.gov/news...
www.kff.org/health-reform/iss....
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[@djphanatik]

If the insurance companies weren’t so devious and deceptive we wouldn’t be in this situation

[@ahealthcarez]

Thank you for sharing your thoughts. Appreciate you watching.

[@victorco.6308]

I am shocked, lawmakers did not care about basic patient protection till 2022?

[@ahealthcarez]

🤷‍♂️ Thank you for watching and for your comment.

[@butterflygirl2285]

IMO - I'm not. They are not subject tot he same restrictions as the underlings/middle and lower classes. Lawmakers serve themselves.

[@victorunbea8451]

The judge is right. The QPA makes any negotiations useless because the QPA is essentially the average of what the insurance provider pays so why would they negotiate if the law basically tells them they get the final say anyway?

[@ahealthcarez]

Thank you for your comment.

[@trevorisle5462]

Fantastic video. Resolved a billing dispute today with this information. Thank you for sharing. 👍

[@ahealthcarez]

Super! Great to hear.

[@buffy6673]

I’m in a situation right now where my partner is in a rehab center and they made me sign a contract for $4000. I found out that they never actually called the insurance company to get an accurate quote and his policy restarts in the middle of his time there so it’s actually gonna cost $9000. We would’ve never gone or waited until October if we had actually gotten an accurate estimate. I don’t think we’re actually protected under this law.

[@ahealthcarez]

Unfortunately, I think you are correct. Meant for out of network doctors at in network hospitals.

[@buffy6673]

@@ahealthcarez I am still going to file the dispute and report them to their state medical board because I do think it was a egregious oversight. Hopefully it’s enough that they’ll make it a standard question in the future and it won’t happen to anyone else at the facility.

[@williamdavidson4576]

Thank you for your informative video. Recently, I received a GFE of $119.00 about a month before a regular doctor visit at the Banner health clinic in Peoria, AZ. I'd been going to this clinic every 6 months for about 10 years and always paid my bill before leaving. 6 MONTHS later, Banner sent me a surprise bill for $56.00, for which nobody in the company - even their office manager could explain why. I asked them if they were aware of the "No Surprises Act" to which they were all clueless. Their answer instead was to send me to a collection agency. And all over $56.00....😳

[@ahealthcarez]

I’m sorry to hear that happened. Thank you for sharing your story.

[@bawer234]

Very nice video summary! For patients, it's important to know that you can play an active role in the billing process. Call your insurer and ask them to reprocess the claim to help cover more of the costs associated with the out of network claim. If they agree, it may be enough to resolve the issue entirely. The dispute is between your insurer and the facility/provider, not you. You pay your premiums, have your insurer pay for their own obligations before you shell out anymore of your hard earned money.

[@ahealthcarez]

Great point. Thank you for watching.

[@fortnersgarden2526]

I have a 5k deductible and have been told that the balances not paid by the insurance company is my deductible.

[@dwkwb8]

Absolutely this. Patients need to put pressure on their insurance carrier to actually negotiate in good faith with the specialties that they know they might need or want. Unfortunately, most peoples insurance carrier is chosen by their job and so switching to a different insurance carrier because they don’t like the coverage or the network is very hard to do without switching jobs.

[@fortnersgarden2526]

I'm glad for your breakdown and for this act. I'm in the midst of managing thru the bills from stint in the hospital. Fortunately, I am well and have the opportunity to review and wrap my head around the incoming bills. From calling the insurance company and the various medical billing agencies, I was introduced to this bill. I'm beyond thankful for it. In retrospect, there was one particular specialist that visited me daily and I was not sure it was necessary. This specialist was OON and, thankfully, this bill makes my portion manageable. Thanks again for your work.

[@ahealthcarez]

Thank you for watching and for your comment.

[@jjvigilante]

Very grateful that you made this video, this is totally unacceptable fraudulent billing activity from health care business. Please keep enlightening us with other knowledges that you have so others will not fall to this trap.

[@ahealthcarez]

Thank you for watching and for your comment.

[@sjgallagher40]

I love how surprised he was in the beginning

[@ahealthcarez]

🤣🤦‍♂️Thank you for watching!!

[@evanjames3011]

Love your videos and explanations

[@ahealthcarez]

Thank you for your feedback.

[@k12balla]

You're a gold mine of great info. Thanks for the informative videos!

[@ahealthcarez]

Thank you for watching and for your comment.

[@akp9083]

Thank you Dr.Bricker.

[@ahealthcarez]

Thank YOU for watching!!

[@annointedpenmanship6840]

So THANK you for this info.

[@ahealthcarez]

Thank you for watching.

[@shaemez]

I just want to leave a comment saying thank you because this topic in general is so poorly understood, even by people working in healthcare. I am doing a grand rounds presentation on health care costs and your videos have been instrumental in directing my research.

[@ahealthcarez]

Super! Thank you for your comment!!

[@jasmine-rojas]

Thank you!

[@ahealthcarez]

Thank YOU for watching.

[@josepaulloor6449]

It’s time an value of your health.

[@annointedpenmanship6840]

Yes. Banner Hospital in Glendale Az STILL does this! Very sneaky. Also Ambulance Svs in Glendale

[@ahealthcarez]

Thank you for the additional information.

[@rendiego1]

Great video Dr. Bricker as always. I remember from way back, probably 10 years back when you / Compass helped one of our clients negotiate down an air ambulance bill when it was completely unnecessary for the company to use air ambulance. Helped save that employee and her spouse around $40K. Keep up the good work!!

[@ahealthcarez]

Thank you for sharing the memory. Thank you for watching and for your comment.

[@super_radd]

That's frustrating to hear for us patients here in Texas. I understand medical profs want to be paid well but now it seems like there could have to be more negotiating if getting that out of network bill. Frustrating

[@ahealthcarez]

Understandable. It’s not good. Thank you for watching.

[@JasonHouse82]

Great explanation, I love the energy and insight. Even with a boring white board you’re entertaining :)

[@ahealthcarez]

Thank you for watching and for your comment.

[@ff-jt8un]

Good on you for bringing up the financial consent form hospitals use. It's often introduced along w/ the medical consent, and explained as just a form that they need to be able to bill insurance. Granted, the patient should read what they're signing, but these hospitals are gambling with the way they've been getting financial consents. As a biller, I have seen waaaaay to many "verbal" financial consents for patients who have no reason to not be able to sign. No AMA or anything, in the hospital under observation for 16 hours...

[@ahealthcarez]

Thank you for sharing your experience. Appreciate you watching.

[@zaboomafoo25]

thank you for the info...and , we should all remember, The Customer Is Always Right ....

[@ahealthcarez]

Thank you for watching and for your comment.

[@michaelomalley3620]

Nice Work - Subscribed.

[@ahealthcarez]

Thanks so much!!

[@AuctioneerElite]

About damn time they close that loophole that ruins family finances. Good legislation

[@ahealthcarez]

Thank you for watching and sharing your thoughts.

[@AuctioneerElite]

@@ahealthcarez my daughter was flown via helicopter at birth in 2017 (she’s perfectly healthy now but at birth she had an unknown complication). I experienced the balance billing of air ambulances out of network first hand. Glad they put a stop to it.

[@marieo9357]

Is there a letter to send collections in Mississippi for this type of bill that I’ve been paying on in a different state? Our insurance didn’t cover it because it was out of network. They kept saying wait for the insurance to pay and that never happened. 🤷🏼‍♀️

[@ecaldwell9]

How do we go about getting a copy of the Poster that has to be posted in waiting Rm? I’m in IL.

[@ecaldwell9]

Are there any exceptions to this Act for Encounter Rate Billing?

[@NicoWei]

Thank you Dr. Bricker. I just had my appendectomy in the ER. and I know there are several out-of -network doctors I have seen. So far, I have received these bill with the in network rate (thanks for the act). However, will my insurance cover 80% for my bill after the deductible? They talked to me that once I reach the out-of-pocket maximum, the plan will pay 100%. But how about before that? Will they also pay 80%? If so, then it looks like no difference as an in network charge, right?

[@ahealthcarez]

In-Network and out-of-network typically have separate deductibles. Insurance also typically only pays 60% if out-of-network, not 80%. I wish you a speedy recovery.

[@frankenstein82]

Thank you for this! Currently fighting with insurance over this. In network deductibles already fulfilled for the year ($1000) The original bill was $1433 for in network ER with out of network provider (ultra sound to abnormal bleeding on wife). Insurance says not covering anything so I told them about no-surprise billing act. They sent for readjustment and today I get a new bill from provider, the balance is $1216.50, and the insurance paid provider $216.50 and still put it under the out of network deductible. This is really irritating because my calculations of it would've had me paying the $216.50 and insurance paying provider $1216.50. Am I fighting this right?

[@ahealthcarez]

Thank you for watching and for your question. If in-network hospital, then should be treated as in-network for ER doctor and facility fee. The insurance company has to take the ER doctor to arbitration to figure out how much they pay them. Hope that helps a little.

[@Outthehouseprod]

Most hospitals now subcontract their ER doctors. Meaning they hire an outside company, a company that isn’t even located in the same state, to staff their ERs as a cost cutting mechanism. So in most cases ER doctors live 2 mins from the hospital, love serving their community, but are OON BY DESIGN not by choice. This isn’t a patient doctor fight as portrayed in this video. It’s a corporate/insurance company fight with patients and doctors caught in the middle.

[@Tru3xEffects]

Could you tell me if this would help with an emergency air helicopter bill of 62k. Our insurance denied coverage saying it is not covered under our plan. 62k is an insane amount that is well over the national average. This was not elected either.

[@ahealthcarez]

Unfortunately no. Contacting your state Senator would be a possible next step. Some states have different laws to protect citizens.

[@DiegoKeel-cl3ov]

Not sure where to post this question, so I put it under this video which had a similar topic. My Doctors office called me (unsolicited) and left a voicemail to call them back. When I called back, nurse asked me if I needed a refill prescription for my meds. I said no, but she continued to ask questions. Finally hung up just after 3 minutes. Two months later I get billed for an office visit for$350. This can’t be legal. Could you please let me know what I can do to dispute this? Or maybe this could be a topic for one of your short videos? Thanks

[@ahealthcarez]

I’ve never heard of that before. That’s terrible!

[@maryspaeth230]

How will this work with an RBP plan? Is that another video subject all together for you?

[@ahealthcarez]

That’s a great question. I have no idea.

[@susanf1566]

My insurance says that my ER copay is $100. I went to an in network hospital. But I'm seeing radiology claims that are out of network because nothing was paid. There are in network discounts on those claims. They still say processing. Are they going into arbitration? I thought I only pay the copay no matter what.

[@ahealthcarez]

You are correct. Would be worth a call to the radiology billing office and your insurance.

[@nikki.3108]

What about being fully covered in your state so you have your procedure 100% covered but they send a biopsy out of state(in network so they claim) so you now get billed triple digits bc it was sent out of state so it goes towards your out of network deductible now?!

[@ahealthcarez]

Likely would need to go to arbitration as per the No Surprises Act: www.cms.gov/nosurprises

[@peterbychowski3860]

Does this affect bills from procedures that were before 2022? I'm disputing a balance bill from 2020 currently and was wondering if this would apply

[@ahealthcarez]

Great question. I do not know.

[@iMaGiNaTiOnWpAsSiOn]

I know this video is old but please help me. Spouse went to ER in August (sepsis) and we went to an in network hospital. Got a bill from the provider who saw him who was out of network. Our bill was already ran through insurance and we paid our responsibility but now we have a $1500 bill from a third party building agency for this provider. My question is (and yes, I made a HUGE mistake), I signed a bunch of papers not reading them. I know, I know. I messed up, but my husband was so sick and I was so scared and stressed and I just signed whatever. My question is, could I have signed a paper waiving our rights to this no surprise act?!?? Or are they not allowed to ask you to sign your rights over for emergency services?

[@ahealthcarez]

Good question. The No Surprises Act should protect you. Best to contact the out-of-network doctor’s practice.

[@kylecaudill9261]

what about an in nerwork doctor billing out of network hospital all of a sudden after the 5th visit?

[@ahealthcarez]

Good question. Sounds like a bad situation.

[@XD9rottie]

What about Medicaid? My mother started getting bills sent to her at the nursing home for an emergency room visit and ambulance ride, despite these companies having her Medicaid card copy. Not sure how to fight them?

[@ahealthcarez]

Good point. I’m sorry that happened to her.

[@subinsasidharan9695]

Great video. On a personal note, just dumbfounded to realise that such logical action by a supposedly conscious humane health org has to be enforced by an act of law...

[@ahealthcarez]

Thank you for watching and for your comment.

[@chandlerkatz8284]

Does the balance billing aspect of the NSA apply to RBP?

[@ahealthcarez]

Great question. I do not think so.

[@rstein3131]

Does one get billed when a resident sees a patient in the hospital?

[@ahealthcarez]

Yes. Thank you for watching and for your question.

[@musthakahamad]

i went to the in network dermatologist but he took some skin samples and sent to Out of network lab and they charged me 1200$ , now i when i checked with my insurance they dont know how to react , how can i apply the no surprise act and save my self from this bill . am from georgia.

[@ahealthcarez]

Unfortunately, I think it is only for hospital services, not for services done in the clinic.

[@kaoyuehhui]

Hi, doctor, thank you for your info. I was ask to pay a balance of 31,680 because my insurer only paid 27,000 to the Air ambulance company. It was in Oct 2020 when I had a heart attack. I didn't know this in- network hospital used this out-network provider. Now I have debt collector comes after me for this balanced bill. Can this Act help me？

[@ahealthcarez]

I don’t think it applies to bills from before when the law was passed. I’m sorry. Marshall Allen on his Substack and in his book ‘Never Pay the First Bill’ has some good ideas on what to do.

[@kaoyuehhui]

@@ahealthcarez thank you so much for your quick response. I really appreciate it. God bless you!

[@asturiasceltic3183]

I need help. I went to get blood work at an out of network lab. The phlebotomist told me and ask me to sign a paper that said any costs my insurance won't pay that i pay. She tumed the computer screen to me snd pointed at $200. I asked if that's how.much it was and she said yes. I then got a bill for over $1000. The. phlebotomist only showed me a portion of the computer screen and cut off the rest. What can i do? Plus, can the phlebotomist get in trouble for deception and fraud? I felt like she cut off the screen on purpose. I even told her my dog's bloodwork was.more expensive at $300 So there was NO misunderstanding on her part since we ralked about it at length snd comparing the price to my dog"s lab work And no way would have i agreed to $1000. $200 yes but not a $1000. I felt i was lied to or she was really stupid. Can i get her for GROSS deception and fraud ? She also billed my provider's office and not my insurance. That's how dumb they are. This was Quest Diagnostics in west Texas. Can a complaint with the USA inspector General do anything?my advice and help is greatly appreciated.

[@ahealthcarez]

I’m sorry this happened to you. You may be able to make some progress by calling the lab directly and work your way up to more senior management. The lower level initial people you talk to will probably not be able to help. You need to get to their boss and their boss’s boss.

[@asturiasceltic3183]

@@ahealthcarez Thank you. Is it against the law what the lab tech did? Would this be part of the "No Surprise Bill " law.?

[@rstein3131]

So, if one goes to the ER and the doctor who sees you is not in network, will that doctor now be covered by your in network benefits?

[@ahealthcarez]

Yes. However, health insurance claims processing is notoriously error-prone, so you will need to stay alert and question every bill and EOB. Good question.

[@rstein3131]

@@ahealthcarez I feel like I have to question every bill. At this point, I know more than the insurance representatives.

[@subinsasidharan9695]

Good. Its median INN rate... not average INN rate 🤣 statisticians will understand

[@ahealthcarez]

Of course!