Surprise Medical Bills

Congress passed the No Surprises Act in December 2020. As legislation evolved over the years, the CAP had worked with federal lawmakers and other physician organizations to improve this policy drastically.

Notably, the final legislation includes three provisions the CAP adamantly pushed for. This includes holding patients harmless, fair reimbursement for care, and efforts to address network adequacy standards. Here are the key details from this victory:

  • Holding patients harmless –Keep patients out of the conflicts and create an Independent Dispute Resolution (IDR) system where insurers and providers settle their differences. The CAP also fought to ensure Congress removed a minimum dollar amount threshold to access IDR and provided the option to batch claims together.
  • Fair reimbursement for quality care – Payment for an out-of-network service should reflect the service's market value based on charges and commercial payments for the service for each geographic area where the service is provided. Insurance companies must make an initial payment for out-of-network services within 30 days of a bill for services or issue a notice of denial. The physician and insurer can then enter a 30-day negotiation period to agree on a payment amount. If the parties do not agree, they can go to the IDR system. The CAP successfully removed any in-network median rate as a benchmark initial payment.
  • Set network adequacy standards – The CAP pushed for regulations that mandate enough in-network providers available at in-network facilities. The new law requires health plans to have up-to-date directories of their in-network providers, which shall be available to patients online, or within one business day of an inquiry. Additionally, the new law requires a study on the adequacy of provider networks by the Government Accountability Office.

Frequently Asked Questions

  • Open all Toggle
  • Close all Toggle

Additional details on the surprise billing process are required by law to be finalized by July 2021. The CAP has been engaged in the law’s implementation and will submit formal comments on any proposed rules released by the Department of Health and Human Services and other agencies.

The No Surprises Act goes into effect on January 1, 2022. This is when the law requires the Department of Health and Human Services to establish an IDR process to resolve billing disputes, health plans must ensure provider directories are current and accurate, etc.

No. The law is applicable to federally-regulated health plans (ERISA, or self-insured plans) and their beneficiaries, as well as state-regulated health plans in those states that have not yet passed their own surprise billing legislation.

No. State laws regulating state-based or non-ERISA health plans remain in effect.