Nebraska NDOI: Enforces No Surprises Act Balance Billing Protections

• The federal No Surprises Act, effective January 1, 2022, protects insured individuals from unexpected balance bills from out-of-network healthcare providers, facilities, and air ambulance services.
• The Nebraska Department of Insurance (NDOI) is the initial point of contact for No Surprises Act complaints in Nebraska, collaborating with federal agencies for enforcement.
• The NDOI first attempts voluntary compliance; unresolved issues or continued billing from providers are referred to the federal government for prosecution.
• Nebraska also has its own Out-Of-Network Emergency Medical Care Act (Neb. Rev. Stat. §§ 44-6834 to 44-6850) providing balance billing protection in emergency situations.
• The federal independent dispute resolution process, utilizing certified entities and the Qualifying Payment Amount (QPA) methodology, resolves payment disputes between providers and insurers.

The Nebraska Department of Insurance (NDOI) plays a pivotal role in the enforcement of the No Surprises Act within the state.

As of January 1, 2022, individuals covered by employer-sponsored health plans or private insurance policies gained significant new protections against unexpected medical charges, commonly known as surprise balance bills. These unexpected charges arise when individuals, often without their knowledge or choice, receive medical services from providers or facilities not within their insurance plan's network, leading to direct billing for the difference between the provider's charge and the insurer's payment. The federal No Surprises Act (NSA) was enacted to address this issue, offering a crucial safeguard for patients.

This federal legislation specifically targets healthcare providers, healthcare facilities, and air ambulance services, ensuring they adhere to new billing standards. However, it is important to note that the No Surprises Act does not extend its protections to ground ambulance services. For those seeking comprehensive information on the federal law, the Centers for Medicare & Medicaid Services (CMS) No Surprises page serves as the primary federal resource, offering guidance and answers to common questions. In addition to the federal framework, Nebraska has its own legislative protections; the Out-Of-Network Emergency Medical Care Act, codified under Neb. Rev. Stat. §§ 44-6834 to 44-6850, provides specific safeguards against balance billing in emergency situations within the state.

The Nebraska Department of Insurance (NDOI) plays a pivotal role in the enforcement of the No Surprises Act within the state. Operating under a Collaborative Enforcement Agreement with federal agencies, the NDOI is designated as the initial point of contact for all complaints related to noncompliance with the No Surprises Act. This collaborative approach ensures that Nebraska residents have a local avenue for addressing concerns regarding Nebraska surprise medical bill protection.

Upon receiving a complaint, the NDOI undertakes an assessment to determine if a healthcare provider, air ambulance service, or health insurer appears to be in violation of the Act. The department's initial strategy involves attempting to achieve voluntary compliance from the non-compliant entity. Should a healthcare provider or air ambulance service persist in seeking payment directly from an insured patient despite these efforts, or if voluntary compliance cannot be secured, the matter will then be escalated and referred to the federal government for potential prosecution. For any required forms or notices under the No Surprises Act, the designated contact for complaints concerning a healthcare provider, air ambulance, or insurer is the Nebraska Department of Insurance, Attn: Insurance Complaints, P.O. Box 95087, Lincoln, NE 68509-5087, with email submissions directed to doi.insurancecomplaints@nebraska.gov, using 'No Surprises Complaint' as the subject line.

Beyond state-level enforcement, the federal No Surprises Act establishes a robust framework for resolving payment disputes, particularly through the federal independent dispute resolution process. This mechanism is designed to mediate disagreements between providers, facilities, or air ambulance services and group health plans, health insurance issuers, or Federal Employees Health Benefits program carriers. The Department of Health and Human Services, the Department of Labor, and the Department of the Treasury are responsible for certifying organizations to serve as independent dispute resolution entities (IDREs), with a continuously updated list of these certified entities available online.

Central to the resolution of these payment disputes, and for determining individual cost-sharing responsibilities under specific circumstances covered by the No Surprises Act, is the Qualifying Payment Amount (QPA) methodology. Comprehensive guidance, including fact sheets, technical resources, and frequently asked questions, is available on CMS web pages, covering topics such as the overview of rules, requirements related to surprise billing, and the implementation of the Consolidated Appropriations Act, 2021. Healthcare providers can also access specific resources, including an overview of Public Health Service Act requirements and a dedicated email question box at Provider_Enforcement@cms.hhs.gov, to address their inquiries regarding compliance and the federal independent dispute resolution process.

Lawyers advising healthcare providers, insurers, or patients in Nebraska must understand the Nebraska Department of Insurance's role as the initial point of contact for No Surprises Act complaints and its collaborative enforcement with federal agencies. They should also be aware of the state's Out-Of-Network Emergency Medical Care Act for emergency situations and the federal independent dispute resolution process for payment disputes, to ensure compliance and advise clients on their rights and obligations.

Source: Original reporting via Nebraska Department of Insurance