New laws under the No Surprise Act will prevent providers from billing patients more than in-network cost-sharing for out-of-network services and will even establish an arbitration process to resolve unexpected out-of-network charges. The new law take effect January 1, 2022 and applies to nearly all private health plans offered by employers (including grandfathered group health plans and the Federal Employees Health Benefits Program), as well as non-group health insurance policies.

Out-of-network providers for emergency services will not be allowed to balance bill patients beyond the in-network cost sharing amount. This same requirement applies to out-of-network providers who render non-emergency services at an in-network hospital or other facility. For example, a patient can receive care at an in-network hospital but have an out-of-network anesthesiologist assists with care. Under the No Surprise Act, the patient will only pay the in-network cost-sharing amount for the out-of-network anesthesiology services.

If the provider is dissatisfied with the payment amount, the payer and provider will be given 30 days to reach a settlement. If a settlement is not reached, the arbitration process can be initiated. A third-party arbitrator must determine which offer is most reasonable, while taking into consideration the following criteria:

  1. The health plan’s historical median in-network rate for similar services.
  2. The level of training or experience of the provider or facility
  3. Patient acuity and complexity of services provided

Once the arbitrator has reached a decision, it is binding and final, and the unsuccessful party will be responsible for the arbitration costs. In the 90 days following the arbitration decision, the party that initiated the arbitration process is “locked out” from taking the same party to arbitration for the same item or service. The goal of this is to encourage settlement of similar claims prior to initiating the arbitration process again. Any claims that occur during the lockout period, however, qualify for arbitration after the period ends.


You can read more about the No Surprise Act here:


About PGM

Physicians Group Management (PGM) is one of the fastest-growing medical billing companies in the United States.  For over 35 years, PGM has been providing medical billing and practice management services and software to physicians, healthcare facilities, and laboratories.  PGM’s current client base encompasses the full spectrum of medical specialties, including Internal Medicine, Dermatology, Plastic & Reconstructive Surgery, Pathology, EMS & Ambulatory Services, Cardiology, Nephrology, Urology, Pain Management, OB/GYN, Gastroenterology, Independent Laboratory, and many more.  PGM’s medical billing and practice management solutions include:

– A full suite of practice management and medical billing solutions each tailored to the specific needs of your practice

– CCHIT-certified electronic medical record software and services

– Streamlined, customized credentialing services for providers of all sizes

– Practice management software that provides advanced financial and practice analysis tools, specifically designed to give enhanced visibility of operations at the click of a button

Laboratory billing software that offers best-in-class systems to streamline, and manage and track, financial and administrative processes