Nevada Consumer Balance Billing FAQs

Please click on the bulleted questions to view the answers. 

• What is balance billing?

Balance, or Surprise Billing, is when a consumer is personally billed the difference between the amount of reimbursement paid by the insurance company to the out-of-network provider and the rate that the provider is charging. For example, you have a procedure that is billed $1,000. Your insurance carrier contracts with in-network provider to reduce this to $500. You are responsible for 20% cost share or $100 and the insurance pays $400 to pay the bill in full. At an out-of-network provider you may be billed the same $1,000 and the insurance may still pay the same $400, but because there is no contracted discount rate, the provider will hold you responsible for the full $600 difference, not just the $100 cost share.

• How can I avoid balance billing?

The best thing to do is to always double check with your carrier and providers that they are in your network. Unfortunately, in emergency situations, this is not always possible.

• Are there any laws against balance billing to protect consumers?

Yes, Nevada has laws in place that prohibit balance billing to the covered person in certain emergency situations. Additionally, a new federal Surprise Billing law that will go into effect 1/1/2022 will offer additional protections.

• My large group insurance plan isn't required to follow all of the same state requirements as the ACA plans. Do I still get the balance billing protections?

After 1/1/2022: Yes, the new federal law also applies to all ERISA plans.

• What is my payment responsibility if I was admitted for an emergency to a hospital that is not in my network?

After 1/1/2022: The hospital and any providers can only hold you responsible for the cost share you would have paid at an in-network provider.

• I was pre-approved for surgery at a hospital that is in my network. I found out after the surgery that the anesthesiologist was not in my network. Am I responsible for these changes?

After 1/1/2022: Anesthesiology is considered an ancillary service. You are only responsible for the in-network cost share for any ancillary service.

• There is only a non-participating provider at my participating hospital that provides the procedures that I need. Do I have to pay out-of-network cost share? Will I need pre-approval from my insurance carrier?

After 1/1/2022:  This is considered as an ancillary service and must be billed at the in-network cost share. The requirements for pre-approval will depend on your specific policy.

• Can I be billed for the out-of-network cost share for a provider at an in-network hospital?

After 1/1/2022: Sometimes. This can happen for non-emergency and non-ancillary procedures provided by a specialist and provided that the out-of-network provider gave notice and received consent at least 72 hours prior to the date of the procedure. Such notice requires that you be given the option to seek care from an in-network provider.

• My spouse had a heart attack and the ground ambulance that picked them up was out of our network. Are we responsible for the additional charges for the ambulance since this was an emergency?

After 1/1/2022: The federal law doesn’t address ground ambulance, so you may be responsible for these charges.

• My insurance covers air ambulance, but the ambulance service used was not a participating provider. What costs am I responsible for?

After 1/1/2022: You will be responsible for the in-network cost-sharing which must be applied to the in-network deductible and out of pocket limits just as if the air ambulance was an in-network provider. Similarly, plan year in-network deductible and out of pocket limits must apply.

• I'm undergoing cancer treatment, but the facility is no longer a part of my network. What can I do?

After 1/1/2022: Nevada state law offers somewhat more protections than the new federal law in this case. You may continue to obtain medical treatment for the medical condition from your provider for up to 120 days after the provider left the network if you are actively undergoing a medically necessary course of treatment, and the provider and you agree that it is best for you to continue your care with them.

Nevada Provider Balance Billing FAQs

The new federal Surprise Billing law covers everything protected under current Nevada state law and more. In situations where the state has stricter statutes to protect consumers, or rules in place determining the rate of compensation due to the out-of-network providers, the federal law defers to the state law. This would be the case for out-of-network providers that were previously in-network within the last 24 months. In this situation Nevada law specifies the formula for computing the rate of compensation. 

• When does the new federal law take effect?

1/1/2022

• Does the new federal surprise billing legislation apply to grandfathered plans?

Yes.

• The new federal law applies to air-ambulances service, does it also apply to ground ambulance?

No, the federal law doesn’t apply to ground ambulance.

• Since there are now state and federal laws in place for the surprise billing of emergency services, which law do we follow for the adjudicating process of the surprise billing? 

After 1/1/2022: In the case of emergency services provided by a non-participating facility or provider, except for critical access hospital , the federal law defers to the state law for the adjudication of the billing. In the case of certain non-emergency services or services provided at a critical access hospital, Nevada law is silent so the federal law will apply.

• What if we do not agree with the initial amount paid by the carrier?

After 1/1/2022: A 30-day open negotiation period begins the day of receipt of the initial payment or denial letter. There is a 4-day window after a failed negotiation period in which the federal law allows for the opening of an Independent Dispute Resolution (IDR). Negotiations may still continue during the IDR process. In the event that the IDR runs through completion, the determination is binding on all parties. The forthcoming rule making for the IDR is to be done jointly between the Secretary, the Secretary of Labor, and the Secretary of the Treasury.

• What facts may be considered in the IDR process?

After 1/1/2022: Market-based median in-network rate, alongside relevant information brought by either party, information requested by the reviewer, as well as factors such as the provider’s training and experience, patient acuity and the complexity of furnishing the item or service, in the case of a provider that is a facility, the teaching status, case mix and scope of services of such facility, demonstrations of good faith efforts (or lack of good faith efforts) to enter into a network agreement, prior contracted rates during the previous four plan years, and other items. Billed charges and public payer rates are excluded from consideration.

• Who pays for the arbitration in the IDR process?

After 1/1/2022: The losing party is responsible for the arbitration costs. This is done to encourage negotiation and discourage weak cases.

• The current state laws allow ERISA plans to opt-in, or not, to the surprise billing statutes pursuant to NRS 439B.757. What legislation applies to these types of plans? 

After 1/1/2022: In the event that an ERISA plan opted-in to the state surprise billing laws, the state laws would continue to take priority when they have stricter guidelines than that of the federal law. Such would be the case of provider reimbursement rates where contracts were in place within the last 24 months. However, in situations where the new federal law exceeds the state requirements, such as in the case of air ambulance, the federal law may apply. Those ERISA plans that opted-out of Nevada’s surprise billing laws may fall under the new federal guidelines. The ERISA preemption clauses and related case law related to such preemption may apply.  The foregoing is not legal advice.  Parties are encouraged to seek the advice of legal counsel for specific answers regarding ERISA preemption and related matters.

• Aside from not balance billing the patient, are there any other requirements for providers and facilities?

After 1/1/2022: Yes. Providers and facilities are required to post a notice of protections against balance billing and how to report violations in a prominent location of the facility, post it on any applicable websites, and provide it to the consumer in a timely manner. Providers and facilities are also required to provide good faith estimates of the expected charges, expected service, and diagnostic codes in advance of a scheduled service.

• What is required of carriers?

After 1/1/2022: Carriers will need to take steps to improve the accuracy of their provider directories and reimburse enrollees who relied upon an incorrect provider directory that results in a bill in excess of the in-network cost-sharing amount.

• Is there a resource to assist providers and facilities on the Federal No Surprises Act?

After 1/1/2022: The Centers for Medicare and Medicaid (CMS) have put together a PowerPoint presentation highlighting the requirements for providers and facilities which can be accessed through the following link: https://www.cms.gov/files/document/high-level-overview-provider-requirements.pdf