A new year is often viewed as a way to make a fresh start, but people advocating for patients’ physical and financial health say Jan. 1, 2022 is significant for what it ends.
That was the date when surprise billing, which once blindsided people who unwittingly received out-of-network medical treatment, came to an end under a new law called the No Surprises Act. It mostly curbs a practice that was prevalent and costly.
One in five people undergoing elective surgery ended up with an unanticipated medical bill because somewhere along the way, a doctor or medical specialist who provided care wasn’t in their insurance plan, researchers said in February 2020.
The average surprise bill was $2,011, according to researchers who reviewed the charges to approximately 350,000 patients.
Almost two in 10 Americans had medical debt as on June 2020, according to a different study. The average amount was $429, researchers said.
Then-President Donald Trump signed the No Surprises Act in December 2020 and President Joe Biden’s administration is putting the law into effect at a time when COVID-19 cases are skyrocketing and hospitalizations are also rising. Amid the omicron variant surge, hospitalizations crossed the 100,000 mark on Monday for the first time since the summer.
The No Surprises Act “is the best tool that American insured consumers have been given to address high healthcare costs in decades,” said Patricia Kelmar, director of healthcare campaigns at U.S. PIRG. “The law is stepping in to protect consumers from an egregious billing practice that has grown in breadth and frequency.”
“It’s going to make a major difference to health consumers,” said Carey Kempton, president of the National Association of Healthcare Advocacy, a professional organization for people who advocate for patients’ care and costs. What worries Kempton is the level of public awareness on the law’s specifics — “which, I think, is not great.”
To be sure, the protection is not absolute and the mix on healthcare and finances gets complicated quickly. Here’s what to know about what happens now.
When No Surprises Act protections do — and don’t — apply
Suppose a person gets rushed to a hospital emergency room with a broken leg and it turns out the hospital was out of their insurance plan’s network.
As the Centers for Medicare & Medicaid Services explained, before the No Surprises Act took effect, the person would owe their side of the out-of-network cost-sharing in their insurance plan. Then, the out-of-network provider could also bill for the difference, or the balance, between what the insurer paid and the rest of the price for treatment.
This is “balance billing,” and when the unanticipated balance bill from an out-of-network provider pops up, that’s a surprise medical bill, according to the agency. (Medicaid and Medicare recipients are already shielded from balance billing.)
The new rules “ban surprise bills for emergency services, even if you get them out-of-network and without approval beforehand,” the agency said. In other words, the law blocks providers from billing someone anything more than their in-network cost sharing amount for a scenario like a trip to the ER, according to the Kaiser Family Foundation.
In emergency situations, the surprise billing protections apply to hospital emergency rooms, freestanding emergency departments and urgent care centers that have a license to offer emergency care, U.S. PIRG noted.
The consumer advocacy organization noted protections on emergency care do not apply to urgent care centers without a license for emergency care, or providers including birthing centers and addiction treatment facilities.
Knowing which urgent care clinics do and do not have the specific licenses might be tricky, Kelmar said. The best bet would be calling ahead to determine licenses in case someone needs to make a quick decision at a later date on where to get treatment.
Now suppose the same person with a broken leg had their accident on a mountain top and needed a helicopter to the nearest hospital. Air ambulances transportation is another context where surprise billing protections apply, the Kaiser Family Foundation said. But the law does not cover ground ambulance transportation.
Ten states already have their own laws against surprise medical bills and there may be protections against out-of-network ambulance bills, according to U.S. PIRG. The states are Colorado, Delaware, Florida, Illinois, Maine, Maryland, New York, Ohio, Vermont and West Virginia, the organization noted.
The best move is calling your insurer to determine if any protections apply, the organization said.
How the No Surprises Act affects bills for non-emergency care
What if someone has scheduled elective surgery or another form of non-emergency care with their in-network doctor at an in-network facility? Surprise bills can still emerge, but the law offers protections too.
Perhaps an out-of-network specialist like a radiologist or anesthesiologist on site teams up with the in-network doctor. The new law prohibits out-of-network charges and balance bills for these types of supplemental services at an in-network facility.
New forms are supposed to tell patients estimated costs — you don’t have to sign
During emergency care, doctors and facilities are not allowed to ask a person to sign documents agreeing to their out-of-network care at out-of-network prices. It can be a different story with non-emergency care.
For some types of care, ranging from post-operation plastic surgery to cardiology, a patient may be asked to sign a form agreeing to out-of-network service at out-of-network charges. The form has to include a “good faith estimate” of what the costs will be, and it usually has to come at least three days ahead of the treatment, according to U.S. PIRG. “The form should also list in-network doctors who are available to provide that same care,” the organization said.
Think hard before signing and don’t feel pressured into it, Kelmar said. “As long as you don’t sign it, you’re not responsible.”
What the No Surprises Act means for bill disputes
There’s the letter of the law. There are also the question how the provisions play out in real life.
“Will providers properly implement them?” said Kempton, who is also the founder and president of Blue Sky Health Care Advocates, where she helps people sort through, negotiate and possibly reduce their medical bills.
The No Surprises Act is coming with a help desk and hotline where patients can ask questions about their protections or file a complaint. The online portal for complaints is here and the help desk number is 1-800-985-3059.
The staffers fielding complaints and questions cannot give legal or medical advice, or say how much money a person should be paying for a service, according to the Centers for Medicare & Medicaid Services. But the agency said they can make sure providers and insurers are following the surprise billing rules and help people understand the documents they need to amass.
The law also has ways for people who do not have insurance to fight unexpected medical costs. The same goes for people who are covered by insurance but still opting to completely pay for their treatment.
In both cases, medical providers have to give a “good faith estimate” on the cost of care. If the final bill is more than $400 above the estimate, there’s a dispute process to figure out the right amount.
The online portal can be found here.
The key question patients should ask to avoid surprise bills
The law certainly helps consumers, but they can also help themselves by being careful with their questions, Kelmar said.
Instead of asking “do you take my insurance,” she said a better way to phrase it is asking something like “Are you part of my plan’s network?”
After all, Kelmar noted a provider could say yes, they do take a person’s insurance — “but what they mean is they will bill your insurance company and still send you that balance bill.”