The No Surprises Act protects patients

The No Surprises Act is a new piece of legislation designed to protect patients from surprise medical bills and balance billing. But what are surprise medical bills, and what is balance billing, exactly? What is a Good Faith Estimate and how can it help with those issues? And how does the No Surprises Act apply to mental health providers and patients?

Because of Good Faith Estimates and the No Surprises Act, mental health patients have more legal protection against surprise billing than ever before. But it’s no help if you don’t know your rights. Here’s everything you need to know about the No Surprises Act and its benefits for mental health patients.

No Surprises Act 2022 summary

The No Surprises Act of 2022 (NS Act) is an important bill for both mental health providers and patients to understand. It’s a pretty hefty piece of legislation, so we’re breaking it up into sections. In this section we’ll cover the aims of the bill. In the next one, we’ll discuss how they actually play out, and whom they affect. 

Here are the three main goals of the No Surprises Act 2022: 

1. The No Surprises Act limits emergency care costs.

• Specifically, the NS Act keeps providers from charging out-of-network (OON) rates for emergency care. 
• We’ll discuss what this means in more detail in the next section. In the meantime, if you’re foggy on the difference between in-network and out-of-network (OON), read our Complete Guide to Out-of-Network Reimbursement. 

2. Under the No Surprises Act, Good Faith Estimates are required by law.

• The NS Act requires providers to disclose all potential fees ahead of time to patients paying out of pocket. This must be in writing, either on paper or digitally. Such a disclosure is called a Good Faith Estimate (GFE). 
• With a Good Faith Estimate, patients can shop around and know what they’ll have to pay. They’re also better protected from surprise billing when going out-of-network.
• The law requires that the Good Faith Estimate be given before any OON medical service is provided. That way, you know what you’re getting yourself into. 

3. The NS Act limits costs for patients on government assistance.

• If a patient is on government assistance (e.g. through a program like Medicaid or CHIPs) the provider must accept a lower payment amount. The government has the right to determine this amount.
• If a provider doesn’t accept a lower payment amount, they can’t bill the patient for it.

Who does the No Surprises Act apply to?

In theory, the No Surprises Act applies to all healthcare providers, including mental health providers. In the Act’s language, the term “providers'' is quite broadly defined. That means that, under the No Surprises Act 2022, therapists, counselors, psychologists, psychiatrists and anyone providing any form of professional medical care is subject to certain rule changes. 

However, in practice some portions of the Act do not apply to mental health providers. This is because much of the No Surprises Act applies to emergency care provided in hospitals. In such cases, mental health providers working outside of hospital ERs are not affected. The gray area that may apply to mental health providers is what the act calls “non-emergency care provided at in-network facilities.” We’ll address this in more detail below.

Still, no matter where care is provided, any provider whose patient pays out of pocket now must give a Good Faith Estimate. The GFE portion of the Act is a universal rule applied to all providers, including mental health practitioners. To make things clear, we’ll go over the three main scenarios in which the NS Act changes healthcare policy. Then, we’ll discuss whether or not they apply to mental health providers. 

1. Emergency Care from an Out-of-Network (OON) Provider

• The NS Act prohibits providers from charging out-of-network rates in emergency care situations. 
• However, the NS Act defines emergency services as care provided in emergency departments of hospitals. 
• Care provided in a physician’s office, like a therapist’s or a psychiatrist’s office, is not defined as emergency care.
• Therefore, mental health providers are exempt from this part of the NS Act. 

2. Emergency Air Ambulance Services

• The NS Act protects patients from surprise billing for OON emergency air ambulance services.
• This scenario does not affect mental health providers.

3. Non-Emergency Out-of-Network Care at an In-Network Facility

• The NS Act prohibits providers from charging patients OON prices for non-emergency care received at in-network hospitals. This is the slight gray area for mental health providers.
• The NS Act defines ‘non-emergency care’ in this scenario as care provided in hospitals. 
• The vast majority of mental health providers are not affected, because they work outside of hospitals. 
• However, if in a rare case a mental health provider treats a patient inside a hospital or hospital outpatient department, the patient may be protected from OON billing.

How does the No Surprises Act apply to mental health providers & patients?

The key element of the law for mental health is the Good Faith Estimate. Because of the No Surprises Act, mental health providers have to disclose all out-of-network fees up-front and in writing. This includes any applicable copayments, coinsurance, and deductibles. (To learn how to find out your OON deductible, coinsurance rates, and more, read How to Check Your OON Benefits. Or try SuperBill’s out-of-network benefits calculator for free!)

Now for an example. Say a patient sees an out-of-network psychiatrist. The patient is expected to pay for the service out of pocket. Next, the psychiatrist gives the patient a superbill which they can send their insurer for reimbursement. But before any of that happens, and before the medical service is rendered, the psychiatrist must disclose the cost of the visit, as well as any additional fees.   

Getting a Good Faith Estimate: No Surprises Act rights and use cases

A crucial element of the No Surprises Act, Good Faith Estimates (GFEs) are worth describing in greater detail. For patients, the GFE rule is simple. Anytime you might pay out of pocket, you are entitled to an estimate of the cost. 

If a provider neglects your right to a GFE, you may be able to reduce the cost to what you would’ve paid for the same service in-network. This is called a network exception. And it happens because the Good Faith Estimate / No Surprises Act makes surprise balance billing illegal. (Balance billing is when an OON provider bills a patient for the difference between the provider’s OON fees and the insurer’s allowed amount. More on balance billing below.)

For mental health providers, many of whom are seen on an out-of-network basis, GFEs are a big deal. Mental health providers should make sure their entire staff is on the same page about the No Surprises Act. Good Faith Estimates are now more than a best practice; GFEs are the law. Neglecting to provide Good Faith Estimates can cost you your money and your reputation. 

What is balance billing, and what are surprise medical bills, exactly?

A surprise medical bill occurs when a patient receives a bill from a health care provider that they didn’t expect. Surprise medical bills can happen when a patient receives care from a provider they assumed was in-network, but who ended up being out-of-network. Surprise billing can also happen when a patient receives care from an OON provider that they didn’t seek out. The most common example of this (and the one the NS Act deals directly with) is emergency room care.

Balance billing is when a healthcare provider bills a patient more than the amount the patient’s insurer pays for the service. The insurer’s standard in-network rate is called an allowed amount. The balance is the difference between the allowed amount and the higher OON cost. It is often billed well after the patient has received the medical service and paid out of pocket.

In the past, OON providers had the right to bill for this balance. Now, the No Surprises Act prevents providers from balance billing in cases where a patient did not expect their care to be out-of-network. On the whole, the No Surprises Act aims to protect vulnerable patients from both surprise medical bills and balance billing.

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