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Government Advocacy

The voice of medical practices in Washington

Engage with a team that advocates on your behalf and translates complex regulations into focused updates on the latest health issues from Washington.

Surprise Billing

As part of the Consolidated Appropriations Act, 2021, Congress passed the No Surprises Act creating new patient protections against balance billing. These new protections not only prevent patients from receiving certain surprise medical bills, but also establishes new patient price transparency requirements. A majority of the provisions of the No Surprises Act are effective January 1, 2022.
 
The No Surprises Act has two main components:
  • Federal regulation of balance billing under certain circumstances, and
  • Patient transparency protections.

The federal regulation of balance billing generally applies to all emergency services and certain care provided by out-of-network physicians at in-network facilities. While the law protects patients from many surprise medical bills, certain eligible providers can meet notice and consent requirements to balance bill patients for out-of-network care.
 
As part of the patient transparency protections, Congress requires all providers, including providers furnishing care in the physician office setting, to provide a good faith estimate (GFE) for care to uninsured or self-pay patients. This requirement takes effect January 1, 2022. Additionally, the law requires providers and insurers to furnish an advanced explanation of benefits to insured patients, however this provision has been delayed and is not effective on January 1, 2022. CMS also announced that it will not enforce the convening/co-provider requirements starting Jan. 1, 2023 as originally planned.

On February 10, 2023, CMS issued a notice that, "Effective Immediately, Certified IDR Entities Have Been Instructed To Hold All Payment Determinations Until Further Guidance Is Issued. Certified IDR entities have also been instructed to recall any payment determinations issued after February 6, 2023."

MGMA Member-Exclusive Resources:

MGMA Advocacy:

Federal Resources:

 

MGMA believes that the information provided related to surprise billing is a reasonable interpretation of complex regulatory and guidance documents. However, MGMA does not render legal advice to its members, and members are not entitled to rely on MGMA summary documents to establish their own compliance status.

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