Offices of the Insurance Commissioner
Allan L. McVey
Insurance Commissioner
No Surprises Act

On January 1, 2022, federal and state legislation is effective giving West Virginia Consumers new protections when it comes to surprise billing.  This bipartisan legislation provides help when a patient has no knowledge or opportunity to choose care from a provider inside of their own health plan’s network.

The No Surprises Act (NSA) looks at specific portions of balance billing, such as care received at an in-network facility by an out of network provider.  The NSA makes it impossible for providers to bill patients more than their in-network cost sharing.  This includes air ambulance services.  

Surprise billing most often occurs in one of two ways.  The first is in an emergency medical situation where the patient is unable to choose their medical provider, and the second is when a patient receives care in an in-network facility and unknowingly has a portion of their care provided by an out-of-network provider.  This often happens with radiology or anesthesia.  

On some health plans, patients can still intentionally choose to see an out-of-network provider.  The NSA requires notification that the provider is out of network at least three days before the procedure or service and a good faith estimate of the cost.  

The NSA provides for an Independent Dispute Resolution (IDR) process to mediate a bill between the provider and insurance company, taking the patient out of the process.  There is a 30 day negotiation period in which the parties try to reach an agreement before the arbitration period.  The NSA and this IDR process even offers some protections for uninsured and self-pay patients.  

More information can be found on the CMS page