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Q4 2021: No Surprises Act leaves payers happy, but a bitter taste for providers

  • Public Equity
  • Healthcare
  • North America

Americans could face eye-watering surprise medical bills even when their doctor was in their insurance network — until a law came into effect this January: the No Surprises Act (NSA).

The aim of the NSA is to protect individuals from being billed at exorbitant out-of-network rates by medical providers that are not part of their plan. For example, even if a hospital is in-network, some providers, such as anesthesiologists, are not. When the patient is unaware they are receiving out-of-network care, they fall prey to unexpected costs. 

But as of January 2022, health insurance companies are by law obliged to cover most out-of-network bills, with consumers to be charged no higher than the median cost for the same service provided by an in-network participant. While the experts we’ve spoken to agree with the premise of the NSA, the waters are murky and there appear to be some unintended consequences. 

One of the main takeaways from a recent Forum Interview was that the NSA greatly benefits insurance companies while being hugely detrimental to providers, as it effectively gives insurers the power to set reimbursement rates. Specialists noted that although a dispute resolution process is available, the starting point for negotiations is median in-network payer rates, which, as it stands, can be manipulated to minimise reimbursement. Other tactics that can be used by payers, to bring costs down, include forfeiting contracts with higher-paying providers.

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