SURPRISE MEDICAL BILLS, THEY’LL MAKE YOU SICK – ALEX BLACKWELL
HOW SURPRISE MEDICAL BILLS ARE HANDLED UNDER THE NON SURPRISES ACT
The federal government passed the No Surprises Act in December 2020. The law, which combats surprise medical billing, went into effect January 1, 2022. In essence, the law protects patients from some out-of-network charges that, in the past, have shown up due to balance billing in the medical industry. The law covers self-insured health plans and employer-insured health plans.
Balance billing is the difference between what the insurance company paid for a medical visit, including the patient’s copay or deductible, and the provider’s charge for the care received. In the past, this occurred when a patient receives care from an out-of-network provider. In-network providers have an agreement with the insurance company on a set cost for types of care that the insurance pays in full.
Surprise medical bills come when a patient receives medical care from an out-of-network provider. This can happen even if the patient has a medical procedure at an in-network facility. For instance, if you have surgery at an in-network facility, you still may have received a surprise medical bill as the anesthesiologist was out-of-network. Under the Surprise Medical Act, an out-of-network provider may not bill more than your in-network copay for covered services performed at an in-network facility.
The law also changes how emergency services are billed. Emergency services covered by your insurance are protected from surprise bills at both in-network and out-of-network healthcare providers. So, an out-of-network healthcare provider may not bill you more than your in-network coverage for emergency services. Although, you are still responsible for copay, coinsurance, and deductibles for in-network care. However, although the law covers out-of-network emergency air ambulance services, it does not cover out-of-network ground ambulance services.
If you are provided emergency services by an out-of-network provider and recover, the provider must inform you before performing non-emergency services. At that point, you have the option to agree to non-emergency care at the out-of-network provider or move to an in-network provider. You should never be asked to waive your protections and agree to pay more for out-of-network emergency care.
You still have the option to receive non-emergency care from out-of-state providers. If you prefer an out-of-network healthcare provider, you can agree in advance to be treated by that physician. The healthcare provider must give you the cost of the procedure beforehand. In this instance, you would pay your out-of-network coinsurance as well as the balance bill.
The law also forces insurance providers to allow pediatricians to serve as your child’s primary care provider even if that doctor is not the primary care provider to the policy holder. It also ensures that insurance enrollees can access obstetrical and gynecological care without going through the approval process set out by insurance plans.
Insurance providers also now have the ability to settle disputes over surprise bills in an independent dispute resolution process. This process lets the insurance company dispute bills with the healthcare provider directly without you putting you in the middle of the dispute.
If you receive a surprise bill, the law has set up ways to investigate. You can file an appeal with your insurance company asking for an external review of the bill. You also have an option to file a complaint with the Kentucky Department of Insurance or the federal Department of Health and Human Services.