Introduction
The health care policy enacted in the past five years is the No Surprises Act (NSA). Healthcare Policies are essential laws and guidelines that benefit the healthcare system, organizations, and patients in many ways. Healthcare policies were and are still established across countries worldwide to prevent poor communication and human error from taking place when it comes to the overall setting of the organization. The No Surprises Act is one crucial healthcare act enacted in 2020 to address America’s existing healthcare problems. This law was needed in the American healthcare setting due to the broad insurance gaps that needed clarification for many people about their accumulating healthcare coverage bills. This paper will discuss the No Surprises Act by focusing on its legislation, facts, the role of APNs in the Act, strengths and weaknesses of the policy, and its considerable impact on policy.
Summarized Policy/Legislation
The NSA was enacted as law in the American Society on December 27, 2020. However, the proposed bill first entered the House in September 2019. In the pre-No Surprises era, health consumers were often placed on surprise medical bills for an extended period after apparently receiving care from either a hospital emergency department or network facilities department. Through the balance billing practice, patients would pay for the difference between their insurer’s payment to a non-network provider and the doctor’s bill. However, these bills could range anywhere from hundreds of dollars to thousands. Non-emergencyTherefore, Non-emergency medical services included services for diagnosing and treating a condition in any setting, including the outpatient department date (Cooper et al., 2020).. In 2020, the No Surprises Act was enacted to eliminate cases of emergency medical services balance billing, irrespective of the physician or hospital network status. This enactment was effected by the 2021 Consolidated Appropriations Act, designed to solve the existing insurance coverage gaps that contributed to endless surprise medical bills. In the healthcare setting, surprise medical bills constantly emerge when healthcare services that do not align with patients’ insurance coverage are directed to patients.
This Act is part of the Consolidated Appropriations Act, an estimated $1.4 trillion legislative package (Congress.gov, 2019). Also, the NSA broadly covers patients’ individual and group health plans and helps establish a proper dispute-resolution process involving providers and programs for self-pay and uninsured people. For Advanced Practice Nurses, this Act means that they will not engage in actions that promote surprise medical bills but instead help patients balance their billing primarily. The APNs will, therefore, improve the health quality of patients during care, advocate for healthcare issues that predominantly affect nurses, bolster the nurse’s wellness and health, promote a more accessible ethical work environment for patients, and maintain high standards of clinical care.
Strengths and Weaknesses of the Policy/Legislation
The No Surprises Act is a better version of the Clinical Healthcare Act, which affects patients’ billing. The main goal of the No Surprises Act is to eliminate skyrocketing care rates, mainly directed to patients outside their healthcare coverage, contributing to surprise billing. From the start, some of the advantages of this Act were that it allowed patients to be put into individualized healthcare where they could be fully protected from out-of-network care provisions and protection from surprise medical bills from out-of-network non-emergencies and emergency services. The Act also offers healthcare funding for the operations run by the government. For patients, this Act comes with more accessible patient financial protections, provider directories, and price transparency, which considerably impact licensed healthcare professions, including APNs, facilities, physicians, and health plans. On the side of doctors and APNs, the good thing is that this law forbids these professions from offering clinical services in emergency settings and network hospitals from patients’ balance billing. With this law, doctors and insurers cannot charge patients for their services aside from their normal network cost-sharing, even if the professional is the only one in the healthcare facility or operates under the in-network facilities (Pollitz, 2021). Thus, enacting this Act has helped break down the legislative impasse and provided a solid basis for consumer groups, employers, and insurers to operate. Also the other important section of the No Surprises Act is the cost-sharing benefit it offers patients, especially in an in-network setting.
In contrast, the No Surprises Act equally has its demerits. From the start, the coverage of this Act is only attained when individuals and groups are subject to services from outside their network provision, are warranted non-emergency services, and even receive emergency services. The other disadvantage of this healthcare plan is that it is not retroactive, implying that it is effective from its renewal date (Cooper et al., 2020). Also, the cases that need to account for referrals nullify this Act’s applicability, which is why patients need knowledge concerning the outs and ins of their coverage. Generally, the Act ensures that the insurance services offered to patients differ from their insurance plan and non-participating providers’ charges, particularly during facility-based services and emergency in-network providers.
Impact on Policy
The No Surprise Act considerably impacts policy in three ways: consumer stakeholders, provider stakeholders, and APRN practice. From the outset, the newest version of the law calls for an independent arbitrator to mediate disputes between providers and insurance companies over surprise medical costs. The Kaiser Family Foundation ascertained that 18% of emergency room visits and about 16% of hospital stays in a provider’s network resulted in a surprise charge (Pollitz, 2021). Surprise medical bills are much more likely to occur in states without protections. The bill would also encourage the enforcement of provider nondiscrimination laws. These laws prohibit insurance companies from denying coverage to entire classes of providers or charging unfair rates for services they don’t cover. Insurance companies use this practice to avoid paying insurance claims. Also, when it comes to the provider stakeholder, the bill puts a restriction on how the healthcare plan should be offered to insurers for certain services, for instance, not providing more than the median in-network rate and not billing holders for both emergency out-of-network services and in-network services.
For the uninsured, this Act means that people without coverage cannot access its services. For this reason, the Secretary of Health and Human Services (HHS) needs to examine the conditions of uninsured patients significantly when solving disputes. The HHS will determine the conditions necessary for obtaining the NAS, its methodology, and the process for resolving payment. In both the consumers’ and APRNs’ practice, the Act sets new requirements for health plans to improve consumer access and increase price transparency for health plan data. This implies that APRNs provide Advanced Explanation of Benefits (AEOB) to patients upon the patient’s request and before scheduled care (American Medical Association, 2021). These benefits are mostly given to patients based on good faith, especially during expected healthcare services. Hence, some benefits that APRNs offer include enrollees’ incurred amounts, expected health plan expenses, out-of-pocket expenses, applicable rate estimates, and information on prior authorization.
The one fundamental impact of this Act is that it sets the basis for both support services and providers and the agreements that bind them. For instance, providers and health plans may not come into agreements that indirectly or directly limit a health plan’s ability to disclose essential information about quality data, cost, and provider-specific pricing from individual market consumers, group providers, or plan sponsors. Also, the Act has considerably impacted the contractual terms of providers’ vital data, claims, and even services. For instance, through this Act, providers abide by some level of disclosure of information limitation, which is subject to interpretation (American Medical Association, 2021). Also, the Act is instrumental as it guides the action of both consultants and brokers on enrollment services compensation, both directly and indirectly. New obligations are imposed on hospital spending information relating to treasure secretaries and labor and HHS, drug spending plan prescriptions, and critical health plan reports. These new disclosure obligations set the direction for drug pricing offered to consumers on the HHS website.
Conclusion
In conclusion, the No Surprises Act was enacted five years in 2020 to address America’s existing healthcare problems of broad insurance gaps. This paper has shown the significance of the No Surprises Act in society by examining its key strengths and weaknesses and its impact on consumer stakeholders, provider stakeholders, and APRN practice. The NSA broadly covers patients’ individual and group health plans and helps establish a proper dispute-resolution process involving providers and plans for self-pay and uninsured people. Some of the benefits of this Act include easier patient financial protections, provider directories, and price transparency. It is thus essential for APRNs to use this Act to promote a more accessible ethical work environment for patients and maintain high standards of clinical care.
References
American Medical Association. (2021). Guide to Surprise Billing Provisions in the Consolidated Appropriations Act 2021. ANA. https://www.nursingworld.org/news/news-releases/2020/ana-urges-the-u.s.-congress-to-pass-the-no-surprises-act/
Congress.gov. (2019, July 11). H.R.3630 – 116th Congress (2019-2020): No Surprises Act (2019-07-09) [Legislation]. https://www.congress.gov/bill/116th-congress/house-bill/3630
Cooper, Z., Scott Morton, F., & Shekita, N. (2020). Surprise! Out-of-Network Billing for Emergency Care in the United States. Journal of Political Economy, 128(9), 3626–3677. https://doi.org/10.1086/708819
Pollitz, K. (2021). No Surprises Act Implementation: What to Expect in 2022. Kaiser Family Foundation, December. https://zymeda.com/stat/cache/files/no-surprises-act-implementation_-what-to-expect-in-2022-_-kff.pdf
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