The No Surprises Act ("NSA") is a federal law prohibiting certain balance billing of persons covered by an insurance product, ERISA regulated self-insured plan, or federal employee health plan and created an independent dispute resolution ("IDR") arbitration process for providers and payors to resolve these reimbursement disputes. The NSA was passed in December 2020 and first implemented on January 1, 2022. Since then, there have been multiple successful legal challenges to the Health and Human Services, Labor, and Treasury Departments' joint NSA regulations and guidance related to the NSA Qualifying Payment Amount calculation methods and IDR procedures. However, the Departments' broad regulations addressing where and how the NSA applies to ERISA regulated self-funded health plans have curiously not been challenged or addressed in the caselaw. The NSA statutory text and regulations apply differing standards as to whether a similar state law governs in place of the NSA, which acts a federal floor on which states can implement and enforce its own balance billing prohibitions, reimbursement dispute resolution processes, and independent causes of action. In reimbursement disputes with third-party administrators of ERISA regulated self-funded health plans, healthcare providers have utilized varied state contract, statutory, and equitable causes of action to redress underpayments of emergency services and care claims -- both before and after the implementation of the NSA. Given the complexities and varied approaches in framing and litigating these disputes, lawyers advising Florida healthcare providers and payors should understand how federal and state laws govern them and their reimbursement disputes when providing emergency services and care.
12:00 PM - 1:00 PM
Balancing Acts: The Intersection of the NSA and Florida's Balance Billing and Reimbursement Laws
Matthew Espino
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