Community Columnists

YOUR LEGAL RIGHTS | How a new health insurance law changes out-of-network medical billing

Attorney David Betras
Attorney David Betras

Over the years, I have developed a fairly reliable way to evaluate legislation: If the American Medical Association, the insurance industry and the U.S. medical-industrial complex hate a bill, it must be a great bill. That is certainly true about the “No Surprises Act,” which took effect on New Year’s Day.

Thanks to the act, which took years to work its way through Congress and survived multi-million dollar lobbying campaigns designed to kill it, patients who have private health insurance will no longer be blindsided by “surprise” medical bills when they unknowingly receive out-of-network care.

The act is both much needed and long overdue. According to the Kaiser Family Foundation, 1 in 5 people who visit an emergency room and 1 in 6 who receive inpatient hospital care receive bills for out-of-network treatment that can reach tens of thousands of dollars.

Bills that high are not surprising, they are shocking, and for years they have brought unsuspecting people to the brink of financial ruin. Fortunately, those days are over.

Now, patients can only be billed for out-of-network services at the rate they would pay for in-network treatment. That means out-of-network emergency services must be covered at the insured’s in-network cost. In addition, out-of-network providers like anesthesiologists who provide treatment at in-network facilities must accept the payment set for that facility.

So, who pays the charges that would have “surprised” patients and families in the bad old days? The act requires insurers and providers to argue over the balance and submit the disputed amount to arbitration if they are unable to make a deal.

While all of this is good news, it does not mean patients can let down their guards or relax when dealing with America’s incredibly — and needlessly — complicated health care delivery system.

For all its good points, the act permits providers to charge the difference between services’ total cost and the insurance payout — called “balance billing” — if patients are given advance notice and then consent. That is why insurance expert Adria Goldman Gross advises people never to sign paperwork allowing an out-of-network provider to balance bill.

“You might see hundreds of thousands of dollars billed to you after completion of the surgery [or] procedure,” she told Forbes Magazine. She also urges patients to ask if the papers they are signing include a waiver of rights.

And there is one more shortcoming in the law: Health care providers and insurers determine which services are covered by the “no surprise” provisions of the law. That means it is up to patients to determine if their doctor or insurance company is trying to pull a fast one and balance bill.

As the Kaiser Foundation notes in its extensive report on the act, even if compliance rates are high — 10 million surprise bills were issued annually in the past — it is highly likely that hundreds of thousands of consumers will receive unjustified charges going forward.

I wish I could say the act includes a simple dispute resolution process that is easy to understand and utilize, but we are talking about the American health care delivery system, so nothing is simple, understandable or easy to use.

But take heart: The U.S. Department of Health and Human Services has set up a “No Surprises Help Desk” with a toll free number: 1-800-985-3059. If you think your insurer or provider has broken the law, pick up the phone and call.

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