What the law of no surprises means for your medical bills | Health, Medicine and Fitness
According to Kaiser Family Foundation polls in 2018 and 2020, more Americans worry about unexpected medical bills than any other expense.
Unfortunately, these bills aren’t uncommon: 18% of ER visits and 16% of hospital stays in the network had at least one out-of-network charge, according to a 2020 Peterson-KFF Health System Tracker study.
The No Surprises Act, which bans most surprise medical bills as of Jan. 1, could allay those concerns.
“This legislation ends the practice of charging patients exorbitant bills for unexpected out-of-network care,” said Senator Patty Murray, Chair of the Senate Health, Education, Labor and Pensions Committee, in an email.
Here are answers to some common questions about the No Surprise Act and what it could mean for your finances.
What is a surprise medical bill?
A suprise medical bill is a bill you wouldn’t expect from an out-of-network provider. They often arise when you did not choose the doctor or did not know that he was not in your network.
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“You don’t control where the ambulance takes you for emergency treatment,” says Patricia Kelmar, director of healthcare campaigns for the United States Public Interest Research Group, or US PIRG, a federation of advocacy organizations. state-based consumers. “You don’t control who anesthetizes you or who does your lab work once you’re in a hospital — in your network hospital.”
Insurers often require copayments, coinsurance, or higher deductibles for out-of-network care. The provider may also charge you for what’s left after your insurer has paid their share of the bill, a practice called “balance billing.”
What does the law do without surprises?
Invoicing of the balance
The No Surprises Act prohibits balance billing for emergency and certain non-emergency services.
First, your insurance must cover in-network emergency services without prior authorization. Balance billing is not permitted for emergency care, even in out-of-network hospitals or emergency departments.
If you go to a network hospital or ambulatory surgery center for non-urgent care, the balance billing is not authorized for any of these ancillary services:
- Anesthesiology, pathology, radiology or neonatology.
- Care by surgeon’s assistants, hospitalists or resuscitators.
- Diagnostics such as radiology or laboratory services.
- Any other item or service from an out-of-network provider, if an in-network provider is not available.
You cannot waive or lose your protection against the balance billing of emergency services or ancillary services at network facilities. All you have to do is pay your co-payment, coinsurance or deductible in the network.
Consent for out-of-network billing
You may want the care of a specific provider, such as a specialist in specialist surgery, even if they are out of the network. An off-grid provider in an on-grid facility can only send you a balance bill if all of these are true:
- The provider is not listed as ancillary services above.
- They give you a plain language explanation of your rights.
- You agree in writing to waive your balance billing protections.
If you don’t consent, they can’t charge you as out-of-network, but they can refuse to treat you.
“I really encourage patients to think very, very carefully before they waive their rights and sign this form,” Kelmar says. “They have every right to request an in-network provider. The hospital must provide them with one… If they want to remain in the network, they do not have to sign the form.
Disputes over what you owe
If you pay for the services yourself, you are entitled to a good faith estimate from the supplier. If a supplier charges you $400 or more above this estimate, you can dispute the invoice.
If you use insurance, your insurer can tell you what is covered and estimate your disbursements. If your insurer denies a claim because it says certain services aren’t covered, you can challenge that decision.
Kelmar and US PIRG have worked with the federal government to set up what it calls a “one-stop shop to go to with any questions or complaints.” You can call 800-985-3059 or visit CMS.gov for disputes or any other problem related to the law without surprises.
Arbitration between service providers and insurers
The No Surprises Act “provides insurance companies and healthcare providers with a fair process to resolve [out-of-network] bills at no additional cost to patients,” said Murray, a Democrat from Washington state.
You don’t need to be involved in negotiations or disputes between providers and your insurer. If they disagree on a payment, they must either resolve the issue themselves or use a new arbitration process.
Although the patients are not directly involved, “we really care about the proper functioning of arbitration,” says Kelmar. “It was very important to us that there was a reasonable payment made to the provider that would not increase the long-term costs for our health plans – which we would then see reflected in our premiums in the future.”
What is not covered by law without surprise?
The No Surprises Act does not prohibit all surprise and out-of-network bills. Here are two important exceptions:
- ambulances: The law covers air ambulances, but not regular land ambulances.
- Facilities: The law applies to care provided in hospitals, emergency departments and outpatient surgery centres. Other facilities such as clinics and urgent care centers are not included but may be added later.
These protections do not apply to those covered by Health InsuranceMedicaid, TRICARE, Veterans Affairs Health Care or Indian Health Services, as they are already protected against surprise medical bills.
Will the no-surprises law affect healthcare costs?
“I worked hard to make sure the bill we passed would end surprise bills in a fair way that wouldn’t increase costs for patients in other ways, like higher premiums.” , Murray said. The No Surprises Act could achieve that goal, according to the nonpartisan Congressional Budget Office, or CBO.
Most health insurance premiums could fall by 0.5% to 1%, according to CBO estimates, so patients and the government would pay insurers a little less.