Edu Resources | Is “Surprise billing” the same as “balance billing?”

For Educational and Research Purposes Only, Not Intended As Legal, Accounting or Medical Advice  — Often interchangeable terminology and meaning(s) which you and/or your team/practice may come across are important to understand and stay up to date on, it’s important to know what they mean and how they may impact your practice. Below we’ve put together a few helpful resources and their sources we hope will help you and your practice with continued research about these terms and question(s).

Surprise and Balance Billing State Policy Options

Source: – We are the nation’s most respected bipartisan organization providing states support, ideas, connections and a strong voice on Capitol Hill.

Surprise medical billing, also known as balance billing, happens when someone seeks care at an in-network facility or provider but receives services that are out-of-network. Many times, patients receive such care without prior knowledge or authorization … In December 2020, Congress passed the No Surprises Act, which outlines several consumer protections and a payment process. Patients who are seen by an out-of-network provider will not be responsible for any amount over their normal cost-sharing requirement for an in-network provider, and providers are barred from seeking anything above this threshold from patients. The law also protects consumers against being surprise-billed in both emergency and nonemergency settings. Payment disputes are resolved by using a “baseball-style” arbitration process, where each party makes an offer and an independent arbitrator chooses between them.


(Map) Surprise and Balance Billing State Policy Options …


Fact sheet

What You Need to Know about the Biden-Harris Administration’s Actions to Prevent Surprise Billing (September 2021

Affordable Care Act

On September 30, 2021, the Departments of Health and Human Services (HHS), Labor, and the Treasury (the Departments), along with the Office of Personnel Management (OPM), issued a second interim final rule with comment period, “Requirements Related to Surprise Billing; Part II,” to protect consumers from surprise medical bills under the No Surprises Act. This rule provides additional consumer protections, including: (READ MORE …)


Surprise Medical Bills: New Protections for Consumers Take Effect in 2022

In the closing days of 2020, Congress enacted and the President signed into law the No Surprises Act, providing new federal consumer protections against surprise medical bills.  The measure was included in omnibus legislation funding the federal government for fiscal year 2021 and providing stimulus relief for the COVID-19 pandemic.  Its enactment followed nearly two years of Congressional debate over competing approaches to the problem that, at times, appeared to be deadlocked.


Surprise billing & protecting consumers

Source: – As of January 1, 2022, consumers have new billing protections when getting emergency care, non-emergency care from out-of-network providers at in-network facilities, and air ambulance services from out-of-network providers. Through new rules aimed to protect consumers, excessive out-of-pocket costs are restricted, and emergency services must continue to be covered without any prior authorization, and regardless of whether or not a provider or facility is in-network.


Page Last Modified: 01/14/2022 02:00 PM