You know the feeling you get when you receive an unexpected bill from a medical provider after seeking medical care. A new federal law went into effect on January 1, 2022, to protect patients from surprise billing. So, let’s break down what is surprise billing and understand what this new federal law does for patients.
Most group health plans and issuers that offer group or individual health insurance coverage have a network of providers and health care facilities (in-network providers) that agree to accept a specific payment amount for their services. Providers and facilities that are not part of a plan or issuer network (out-of-network providers) usually charge a higher rate than the contracted rates given to in-network providers. Patients are responsible for the higher out of pocket cost from out-of network providers when their health care plan does not cover the entire cost of the service
This “balance bill” may come as a surprise for many people. Often a patient may have gone to a facility that they thought was in network, but they unknowingly get medical care from a provider, facility, or provider of air ambulance services outside their health plan’s network. Surprise billing happens in both emergency and non-emergency care settings. For example, you go to your doctor to get a physical and the lab work was done by a facility that is out of network. You are responsible for the out of network rate for the lab work even though your doctor’s office may have been in network
In an emergency, a patient usually gets care at the nearest emergency department. Even if they go to an in-network hospital for emergency care, they might get care from an out of network provider at that facility. The No Surprises Act protects patients from large and unexpected surprise bills under these circumstances.
Under the new law, patients would be charged in-network fees for:
➢ Emergency services.
➢ Patient copayment, co-insurance, or deductibles for emergency services cannot be more expensive than the in-network rate of the facility and provider.
➢ Patients cannot be charged for items or services at an in-network facility unless they are provided certain notices and consent is given by the patient.
If there is a dispute between the provider and the insurance company the two will be required to participate in arbitration and leave the patient out of the dispute. Remember the surprise billing act applies to hospitals, physicians, air ambulances, urgent care centers, and other medical professionals. It does not apply to ground ambulance services.
Uninsured (Self-Pay) Patient
If an uninsured patient is scheduling a service, a facility must provide a good faith estimate of expected charges for items and services. If the bill is substantially more than the good faith estimate the patient can go through the dispute resolution process. So, what is “substantially in excess”? HHS has said $400 more than the estimate.