What You Need to Know
- EMTALA is the federal law that has governed how hospitals deliver emergency care.
- The new federal No Surprises Act uses an entirely different definition of what an emergency is.
- A health tech expert says the new law may lead to insurers and hospitals signing new, reimbursement-only agreements.
The new federal No Surprises Act (NSA) could force U.S. hospitals to play more gently with insurers, and possibly increase the amount of care they provide for uninsured patients.
The act has many pieces. One well-known part could help any insured clients you have who get emergency care from hospitals outside the insurers’ provider networks.
Hospitals that are “part of a plan’s provider network” have signed agreements that may cover everything from what they charge for liver transplants to how quickly plans must pay claims.
Today, in many states, an out-of-network hospital can bill your client as much as they like for emergency care. A health insurer may be able to pay what it defines as “usual, customary and reasonable” amounts for the care and leave your client to fight with the hospital over the balance.
The NSA calls for the hospitals and insurers to eliminate “balancing billing” of patients for emergency care. Hospitals and insurers will have to wrestle over an eligible patient’s balance with each other, with help from mediators.
Federal agencies posted draft NSA regulations in early July.
Matthew Albright, chief legislative affairs officer at Zelis, a health care payment technology company, is one of the many health policy watchers trying to figure out what the new emergency care reimbursement rules will really mean.
Before Albright went to work for Zelis, he spent about four years at the Centers for Medicare & Medicaid Services, one of the agencies in charge of implementing the NSA emergency care reimbursement provisions.
Here are five things he’s seeing, drawn from answers to a recent email interview.
1. The new NSA definitions of “emergency services,” “emergency medical condition” and “to stabilize” a patient could affect how hospitals define “emergency services” in other situations.
The federal Emergency Medical Treatment and Active Labor Act of 1986 (EMTALA) requires hospitals to stabilize all patients who come in facing medical emergencies, regardless of those patients’ ability to pay for medical care.
EMTALA is one reason U.S. hospitals face large uncompensated care totals.