No Surprise Act Update and Resources

February 22, 2022 4:11 PM | Maggie Gruennert (Administrator)

No Surprise Act Update and Resources
Written by: Lisa Maurer, MD - Legislative Committee Chair

As of January 1st, the No Surprises Act prohibits emergency physicians from billing patients for the balance of charges after an out-of-network payor pays for the services, a practice historically referred to as “balanced billing.” Relatedly, it provides a mechanism for negotiation and arbitration if the physician does not find the payment to be reasonable. WACEP has been closely tracking progress of this federal law, participating in federal advocacy on behalf of emergency physicians as the regulations have been released over the last year, and is now staying up to date on implementation in our state.

National ACEP has published a fantastic website displaying an overview of the No Surprises Act with infographics and tables.

In Wisconsin, almost all processes for out of network billing will revolve around federal law, regulation, and enforcement of those requirements. As opposed to some other states, Wisconsin does not have it’s own law governing balanced billing practices and determination of payment for out-of-network services. The Wisconsin Office of the Commissioner of Insurance (OCI) recently held a public hearing where it was outlined what portions of the new federal process they would be responsible for enforcing as opposed to federal CMS. OCI will be enforcing compliance for claims for services provided to patients insured by individual and group commercial insurance products. CMS will enforce compliance for federally regulated ERISA (employer funded) insurance products. CMS will oversee all remaining processes including determination of qualifying payment amounts and independent dispute resolution.

There are multiple lawsuits currently in process against the federal government regarding the regulations that determine how arbiters would determine the reasonable payment amount for out of network services. ACEP is involved in one of those lawsuits, having filed suit against the federal government along with the federal specialty societies for anesthesiologists and radiologists, charging that the rules released last year are in conflict with the law that Congress passed in late 2020. Although we must move forward with processing bills according to the rules as they stand now, WACEP will keep you informed of any changes based on legal action going forward.

If you would like to receive updates regarding the No Surprises Act from the Wisconsin OCI, please request that you be added to a recipient list by emailing ocinsacomplaints@wisconsin.gov with your name, email, phone number and address. For more information, please see OCI’s summary of the No Surprises Act or feel free to contact WACEP at WACEP@badgerbay.co