May 24, 2022

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The No Surprises Act Took Effect January 1; Here’s What It Means For Your Medical Bills

If you’ve used an emergency room or been hospitalized in the United States, there’s a good chance you’ve gotten a medical bill that caught you by surprise. One in five Americans has received a surprise medical bill from an emergency department visit; nearly as many have gotten unexpected bills from nonemergency hospital stays.

These bills are more than a nuisance for many; they can cause anxiety and financial hardship. Two out of three Americans say they worry about being able to afford unexpected medical bills and nearly half can’t afford to pay surprise bills in full.

Now, many surprise medical bills are poised to become a thing of the past, thanks to the No Surprises Act, which took effect on January 1, 2022.

The new law, passed in late 2020, provides consumers with federal protection from unexpected out-of-network medical bills—bills from healthcare providers who don’t participate in the patient’s health insurance network. 

Out-of-network charges are common in emergency care, where consumers don’t necessarily have a choice in where they go or who provides their care. These charges can also arise during nonemergency hospitalizations, where multiple providers may be involved in care. Even if a hospital participates in a patient’s insurance plan, specific providers, such as anesthesiologists or radiologists, may not. Consumers may have no idea that they’re getting care from out-of-network providers and no say in it either.

That’s now set to change. 

The law requires that private health insurance companies cover certain out-of-network bills and apply consumer copayments or other costs as if the care had been delivered by in-network providers. It also prohibits doctors and hospitals from charging consumers more than they would have to pay for the applicable services if the providers were in-network with the insurance company.

The No Surprises Act applies to bills for emergency services provided in hospital emergency departments, freestanding emergency facilities, and urgent care centers that provide emergency services. It also covers air ambulance transportation—but not ground ambulance—and nonemergency services provided by out-of-network providers who may practice at but bill separately from in-network facilities.

What the No Surprises Act Means for You

Though hospitals and other healthcare providers have had a year to get ready for the implementation, the full extent of the law’s impact on consumers is unknown. 

Adria Goldman Gross, a New York State-licensed insurance broker and founder of MedWise Insurance Advocacy, is concerned about how the law’s implementation will actually work. She urges consumers to exercise caution.

“With this new law, my advice is to be sure that you never sign paperwork allowing an out-of-network provider to balance bill you,” Gross said. “You might see hundreds of thousands of dollars billed to you after completion of the surgery [or] procedure.”

The practice Gross refers to—balance billing—is when a provider bills the patient for the gap between the provider’s fees and the portion of those fees that insurance pays. Balance billing is not allowed for people insured by Medicare and Medicaid, but until the No Surprises Act, nothing prohibited it in private insurance.  

Under the new law, providers are required to notify patients—and post publicly—their surprise billing protections. 

If you’re asked to sign a consent form that allows the provider to balance bill you, the new law requires that the provider give you an estimate of charges 72 hours in advance unless the services are scheduled sooner.

According to the law, you can’t be asked to waive your protections against balance billing in emergencies or for certain nonemergency services, such as ancillary services (anesthesia, pathology, radiology) associated with emergency care or diagnostic services such as radiology or labs. 

“Just imagine yourself being unconscious or so sick it’s almost impossible to read anything,” Gross said. 

But in other scenarios, if you refuse to give consent, the provider could decline to treat you. 

If you’re not sure what you’re signing, ask if you’d be waiving your rights to be protected from balance billing. Gross also suggests writing on the agreement you’re asked to sign that you will not pay if they balance bill you and to initial that statement to make your intention clear.

It will be up to providers and health plans to identify which bills are subject to No Surprises Act rules. That means that if you get a bill that should have been protected by the No Surprises Act, you’ll have to figure that out for yourself and work to hold the provider and health plan accountable. 

You can appeal your health plan’s decision not to cover applicable charges. If the plan upholds its initial denial, you can now pursue an external appeal with an objective third-party.

You can also seek assistance from the appropriate regulatory authority, but who that is depends on what type of health insurance you have. For example, the U.S. Departments of Labor and the Treasury are responsible for regulating self-insured group health plans, which are offered by many large employers. Fully insured health plans are primarily regulated by states.

You don’t necessarily need to know these details to get help. If you’re not sure who to turn to or if you have general questions about the new law, contact the newly established No Surprises Help Desk at 800-985-3059. 

If you try to fight surprise bills on your own and don’t succeed—or if you need help to fight it in the first place—you can turn to patient advocates who specialize in healthcare financing. 

Most importantly, Gross says, stick with it, especially now that there are added consumer protections.

“I tell people not to give up,” she said. “You need to fight for your rights.”

https://www.forbes.com/sites/debgordon/2022/01/03/the-no-surprises-act-took-effect-january-1-heres-what-it-means-for-your-medical-bills/