Surprise medical bills are often a result of an emergency or when a patient doesn’t get all the information they need before getting care.
Starting in 2022, the No Surprises Act bans balance billing – where out-of-network providers bill patients for more than the in-network cost-sharing amount due under their health plan – on almost all out-of-network services. The law also creates a new final-offer arbitration process to determine how much insurers must pay nonparticipating providers for surprise bills.
How to Stop Surprise Medical Bills Under 2022 Law
Patients should be aware that the 2022 Law provides new protections from surprise medical bills when they receive emergency care and certain scheduled services in hospitals, including ambulatory surgical centers. In addition, if they get care from a provider outside their health plan’s network, they can only be charged based on in-network rates.
It is also possible for a patient to submit an independent dispute resolution application if they believe their insurance company has wrongfully denied coverage or overcharged them for a service. However, this option is not always available to consumers, and the number of appeals is low compared to other denials in federal marketplace plans.
Studies show that surprise billing occurs in 1 in 5 emergency room visits and 9% to 16% of hospitalizations for non-emergency services. It can be terrifying for patients with high deductibles or out-of-pocket costs.
In many cases, surprise bills come from providers who are not contracted with a patient’s insurance company and are not chosen by the patient. These are sometimes called “out-of-network” or “nonparticipating” providers.
If the provider is not in the patient’s health plan’s network, they must ask the patient to sign a surprise bill certification form before they provide services. The patient must then send a copy of the document to their insurance company and wait for the carrier to process the claim and pay the amount within its contract with the provider.
Another way to stop surprise medical bills is to know what your healthcare plan does for you and understand your deductibles, copays, and out-of-pocket costs. You can find out what your plan will cover, how much you will pay, and how to file a claim for a service at the plan’s website that surrounds you.
The NSA requires a health plan to notify patients of surprise charges for emergencies or certain non-emergency services provided by a healthcare provider not in the health plan’s network. These include anesthesiologists, radiologists, pathologists, and labs.
Examples of Patients Getting Surprised Medical Bills
Unexpected medical bills are top of the list of costs many Americans worry about. Two in three adults are concerned about their ability to pay unforeseen healthcare costs.
Surprised by medical bills can be particularly frustrating for people with health insurance. Millions of people a year get surprised out-of-network healthcare charges. Those costs can be a significant portion of the total medical bill.
Patients are most likely to get surprise out-of-network health bills when treated in an emergency room. This can happen when a patient does not know their doctor is out of network or they receive emergency services unexpectedly (such as when they are airlifted to a hospital by a ground ambulance).
Another common type of surprise out-of-network health bill occurs when a patient receives professional services from an out-of-network provider. These bills can include doctor office visits, specialty care (e.g., a radiologist), and laboratory tests.
Some health plans have particular requirements to avoid surprises. For example, some programs require a Surprise Bill Certification Form that the patient signs when seeing an out-of-network doctor. The form is a good way for patients to know what they will owe before they see the provider so that they can plan their healthcare expenses.
Several states have passed laws to protect consumers from surprise out-of-network bills for professional services. These laws apply to out-of-network emergency services at a hospital, ER, or freestanding ER and to assist at a hospital, ambulatory surgery center, or another out-of-network facility.
Federal law is now taking steps to help stop surprise medical bills for most private insurance consumers. The 2022 law will make it easier for patients to dispute out-of-network surprise bills. It will also create a federal system for resolving disputes between health plans and out-of-network providers.
For the surprise, the health plan and the provider will have a 30-day window to negotiate payment amounts for out-of-network health bills. Then, an independent dispute resolution (IDR) entity will then determine if the proposed amount is reasonable and fair. The IDR process is similar to baseball-style arbitration and uses a neutral third party to determine the best offer. The Congressional Budget Office has estimated that using IDR would reduce surprise out-of-network healthcare costs, but it is unclear how much it would reduce the cost to health insurers.
Pros and Cons of the 2022 Law
The 2022 Law is a victory for patients who are often surprised when they receive medical bills from out-of-network hospitals and doctors. Studies show that up to 1 in 5 emergency room visits and 9% of in-network hospitalizations for non-emergency care include surprise bills from out-of-network providers.
The law bans most surprise medical bills from out-of-network providers and makes it easier for consumers to understand their health insurance rates before receiving services. In addition, it limits balance billing to patients in the same plan as their out-of-network provider and requires providers to notify their patients about the new protections before sending out bills.
Some experts believe the law will help lower costs. For instance, one study estimated that the law would stop about 12 million unexpected healthcare bills in 2022. Another study found that the law could prevent up to $1 billion in medical costs by 2022.
But the law will also be a challenge for health plans and providers. It will require them to monitor and report on the prices they charge and pay for surprise medical bills and the characteristics of programs and providers that use its dispute resolution processes.
Monitoring and evaluating the law’s impact will rely on various data sources, including the annual health plan audits conducted by federal agencies. It will also depend on new national consumer complaint systems and analysis of all-payer-claims databases.
Researchers have already looked at how the law may impact health costs, provider networks, and the role of private equity firms in provider network formation. These studies will be critical for identifying adverse effects and adjustments to the law.
Some of these issues include whether the law has a positive effect on reducing out-of-network claims and whether the cost savings it achieves are significant enough to compensate for the loss of market share of health plans and providers. Other researchers have studied the effect of the law on clinical laboratory tests, which are particularly susceptible to balance billing.
The law will take years to implement fully and will be challenging to monitor, so it is crucial for health plans, doctors, and other stakeholders to educate patients about the laws and how to navigate them. It is also essential for patients to be able to get in touch with their health plan to dispute a surprise medical bill.
Final Words
Suppose you’ve ever browsed the internet for last words. In that case, you’re familiar with people putting down on paper or video what they consider to be their final wishes or instructions. These messages are usually written or spoken to remind family and friends that God still reigns.
For many, the best last words are also the most memorable. It’s one of the reasons why I created The Final Words Project, a repository of inspirational quotes and sayings by notable people throughout history.
Regardless of what you choose to do with your final wishes, they should be clear and direct. This is particularly true if they involve the passing of a loved one or the finality of the end of your own life. The more you can communicate with your loved ones in advance, the better off you will be.
The new No Surprises Act makes this possible in most states, but you’ll need to do some legwork and research before you can reap the benefits. Fortunately, there are plenty of resources out there that will help you put your wish into action.
The biggest challenge is finding out what the law entails and how to apply it to your specific situation. Here are some tips that should help you get started. The first step is determining whether the No Surprises Act covers your claim. If it is, the next logical step is to dispute the bill. Most state regulators have a page dedicated to helping consumers navigate the healthcare system, so do a little internet surfing and see what is available in your area.
