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Legal Challenges to No Surprises Act Regulations Leave Dispute Resolution Process in Flux


Enacted at the end of 2020, the federal No Surprises Act (NSA) prohibits certain health care providers and facilities that provide their services outside of health plan provider networks from "balance billing." As a result, those providers and facilities cannot hold patients responsible for the difference between what the provider or facility charges and what health plans or other third-party payers pay for the services. In this article, Joanne Roskey reviews recent court decisions that have put the rules for determining how much health plans and insurance companies pay those out-of-network providers who are prohibited from balance billing under the new law in flux, further complicating the already complex system for paying health claims. Roskey notes that benefits professionals should anticipate further guidance from federal agencies as they attempt to develop a workable process for determining out-of-network payment rates. She concludes that as a practical matter, the current delays in payments to providers and uncertainties surrounding the criteria to be used in calculating out-of-network payment rates may work to encourage more provider network participation and overall health care cost reductions for plan sponsors and participants. Whether Congress steps in to amend or clarify the NSA, or engage in further oversight of its implementation, also remains a possibility.