By Shelby Smoak
In January 2022, the No Surprises Act took effect. This bill is meant to end those nefarious charges that appear on explanation of benefits (EOB) listed as “OON” or Out-of-Network and are the result of care received at in-network facilities.
What Is a Surprise Bill and How Does It Happen?
Basically, a surprise bill is an unexpected bill. These are often the result of an out-of-network charge when receiving services at an in-network facility. A majority of surprise bills are related to emergency (ER) services. In these situations, providers often have to act quickly, and they may not be fully equipped for diagnosis and treatment within the facility. They may be using contracted help—such as an X-ray being read by an outside source; hence, you have in-network services (at the ER) but an out-of-network provider (X-ray technician).
What Does the No Surprises Act Cover?
According to the Centers for Medicare & Medicaid Services (CMS), the No Surprises Act provides consumers with “billing protections when getting emergency care, non-emergency care from out-of-network providers at in-network facilities.”1
What Situations Does the No Surprises Act Not Cover?
The No Surprises Act does not protect you if your provider (ER, hospital clinic or other facility) is out-of-network. To be applicable, the out-of-network claim in question must have occurred within or at an in-network facility or provider.
Will the No Surprises Act Automatically Take Effect When I Receive an Out-of-network Bill?
No. The Act provides you with the protection to challenge the charge, but it does not require providers and insurance plans to flag out-of-network claims, nor are they required to determine if one of your out-of-network claims meets the criteria of a surprise bill.
How Can You Determine If Your Claim Was an In- or Out-of-network Claim?
On most Explanation of Benefit (EOB) claim forms, these are noted or coded as OON (out-of-network).
How Do I Dispute a Medical Claim That I Think is a Surprise Bill?
If you believe you are the victim of a surprise bill, you can challenge the charge with the insurer and provider.
The No Surprises Act is new to 2022 and is likely to have some bumps, but it’s important to know the law and know your rights. If you have any questions, please reach out to your RCC at BioMatrix or our education team at education@biomatrixsprx.com. We hope this helps you stay protected in 2022 and forward.
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Reference
CMS. “Surprise Billing and Protecting Consumers.” 14 Jan. 2022. https://www.cms.gov/nosurprises/Ending-Surprise-Medical-Bills
