This article is brought to you by AHLA 's Health Care Liability and Litigation Practice Group.
The interplay of continuity of care obligations under provider agreements and legislation at both the state and federal level, including the No Surprises Act, poses challenges to both payers and providers. This article offers an overview of the multitude of requirements and outlines a strategy for avoiding potential liability.
Provider agreements are commonplace in the health care industry. They create a network of hospitals and providers (among others) that provide care to members enrolled in a specific plan at a negotiated rate. Of course, providers may shift from being in-network to out-of-network for a variety of reasons, including upon the termination of a provider agreement.
When a provider agreement is terminated, an important issue arises related to patient care: what are the continuity of care obligations following termination? While providers and payers often negotiate and expressly outline these obligations in their provider agreements, Congress and state legislatures have determined that contractual protections may not be enough to guard against the potential disruption to patient care and surprise billing from the sudden termination of a provider agreement. Toward that end, the federal No Surprises Act, which took effect in 2022, requires that providers and payers ensure a patient continues to receive care and coverage for extended periods of time. A patchwork of state laws and regulations provide similar-and sometimes greater -protections. Providers and payers alike should have compliance with these private and public requirements on their radar.
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