- Certain unexpected medical bills are now banned under the No Surprises Act, which went into effect Jan. 1.
- "There are a number of loopholes and nuances that consumers must be aware of in order to ensure they are protected," says Kim Buckey, vice president of client services at DirectPath.
- Consumers should still watch out for these charges and know what to do if they’re hit with one.
After going to the emergency room or undergoing a medical procedure, an unexpected medical bill can feel like salt in the wound. For example, say "you find out that the anesthesiologist was out-of-network and you get this horrendous bill that you weren't expecting," says Kim Buckey, vice president of client services at DirectPath, a consumer and employer healthcare advocate company.
To protect patients, the No Surprises Act went into effect at the beginning of 2022. Under the new federal law, people covered under group and individual health plans can't receive a surprise medical bill when they receive most emergency services, non-emergency services from out-of-network providers at in-network facilities, or if they're transported to a hospital by air, like in a helicopter or airplane.
Prior to the No Surprises Act, surprise billing was common, even among those with private insurance —nearly 1 in 5 patients who went to the emergency room, had an elective surgery, or gave birth in a hospital received surprise bills, with average costs ranging from $750 to $2,600 per episode, according to the U.S. Department of Health and Human Services.
However, the No Surprises Act "is not as straightforward as it may seem," says Buckey. "In fact, there are a number of loopholes and nuances that consumers must be aware of in order to ensure they are protected, and failure to do so can cost thousands."
You still need to be on the lookout for surprise medical charges, Buckey says. Here are three things you can do to head off unexpected bills.
Under the No Surprises Act, "if you go to the emergency room, you can't get those unpleasant surprises, like an out-of-network bill from the anesthesiologist," Buckey says. "If you are receiving emergency room treatment, that has to be covered as if it were in-network, even if you were at an out-of-network facility."
Even though hospitals are not allowed to surprise bill you, it's possible not every hospital will comply with the new law. "If you're in the emergency room and you're in a position to, note every doctor you see, every test that was ordered, and all of the medications you were given," Buckey says. If you're unable to keep detailed notes, see if a family member or friend can.
"Always ask for an itemized bill when you're discharged from the hospital," she adds. That way you can see if there were any unfounded charges.
If you suspect you're being billed for services that should be covered, call your insurance company, Buckey says.
Outside of the emergency room, if you are getting a common procedure like a colonoscopy, a heart surgery, or an orthopedic surgery that you've had planned for weeks or months, the No Surprises Act helps protect you, too.
Before the No Surprises Act, an out-of-network provider or facility could do something called balance billing, which is when you are billed for the difference between the billed charge and the amount your health plan paid. Some states already banned this, but now it's banned at a federal level.
For example, "the out-of-network provider may charge you $1,000 and the insurance company is only going to pay $400 of that, so then the provider could turn around and charge you as the patient the remaining $600," Buckey says.
Under the No Surprises Act, you can only be balanced-billed "if they [the provider] notifies you they are out-of-network, give you a good faith estimate of their charges, and tell you what network providers are available that they can refer you to (if the facility is in network)," Buckey says.
All the same, if you know you have a procedure coming up, "it's so important to shop around," Buckey says. The same procedure can vary in cost dramatically by zip code, even if it's with an in-network provider.
"Even if you have insurance, why would you want to pay, say, 20% of $5,000, when you could pay 20% of $1,500 and get the same quality care?" Buckey says.
Before being treated out-of-network, you are supposed to be provided with what's called "an advance explanation of benefits," Buckey says, "which will give you an estimate of the total cost of care and what your share of cost is expected to be, based on where you are in terms of meeting your annual deductible."
The provider may ask you for a statement of consent, stating you'll be responsible for the balance bill and "if you agree, they can bill you. If you don't agree, they can refuse to treat, or, if they treat you, they cannot balance bill you," Buckey says.
In order to make sure you're getting charged the correct amount, "health plans are required to offer price comparison information over the phone and on their website that allows you to compare prices for a specific item or service," Buckey says.
If you're overwhelmed, "ask whether your employer offers advocacy and transparency services. This can save you a lot of time on the front end, when scheduling and doing cost comparisons, and on the back end, when dealing with claims and billing disputes," Buckey says. "If they don't offer an independent service, check to see if your plan's insurance carrier offers something similar."
As long as you're equipped with this information, you should be able to better protect yourself from surprise medical bills, Buckey says. Especially since, often "health care is the one service that we 'buy' without knowing what the cost of service is upfront."
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