What if you get one


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The No Surprises Law, which protects privately insured patients against surprise medical bills, will come into effect on January 1. Drazen / Getty Images
  • On January 1, 2022, Americans will be protected against surprise medical bills under the No Surprises Act.
  • Surprise medical bills arise when a patient consults an out-of-network provider without being held responsible.
  • Insurers and providers will negotiate balancing bills, leaving patients out of the middle.

As of January 1, 2022, new law will come into force that will end surprise medical bills for insureds receiving emergency medical care and other health services in the United States.

Congress passed the No Surprises Act last December with bipartisan support, establishing new federal protections against surprise medical bills.

But what types of medical bills are covered by the law, how does it protect consumers and affect overall healthcare costs and premiums?

Healthline spoke with two health policy experts to shed some light on these issues.

The No Surprises Act defines medical surprise in a specific context.

“This is important because there are many situations that can be surprising but don’t fall into that official bucket of surprise medical bills,” said Jack Hoadley, PhD, Emeritus Research Professor at the Health Policy Institute at the McCourt School of Public Policy of Georgetown University. .

These situations can include not knowing that your health insurance plan has a high deductible or that a certain procedure is costing so much.

While such invoices can certainly be surprising, they are not covered by the No Surprises Act.

“When we talk about surprise medical bills for the purposes of the No Surprises Act, we mean situations where you end up using an off-grid health facility or health care provider, usually through no fault of your own,” he said. Hoadley explained.

This happens most often in emergency situations.

If an ambulance takes you to an off-grid hospital, for example, you could receive an expensive surprise medical bill for the services rendered.

“It’s not something you chose,” Hoadley said. “You went to any hospital you were taken to.”

Even in hospitals that are part of your insurance plan’s network, there are situations where a visiting doctor is out of the network. This can happen during an urgent or elective procedure.

“So even if you have done your due diligence and selected a network facility and selected a network surgeon to perform your procedure or a network obstetrician to deliver your baby, while you are at it you may also be treated. by an anesthesiologist, radiologist, or off-grid cardiologist, ”Hoadley said. “And again, this is not something that you have been told about or that you could control.”

The result of these scenarios is often a surprise bill asking people to pay the “balance bill,” or the difference between what the insurance company paid and the total billed.

Research has found that one in five emergency department hospitalizations can lead to surprise medical bills.

Studies show that surprise medical bills average more than $ 1,200 for anesthesia, $ 2,600 for surgical assistants and $ 750 for childbirth.

The No Surprises Law ensures that privately insured patients will not pay more than the network tariff when treated in off-grid facilities or by off-grid healthcare professionals without their consent.

“On January 1, patients will be protected against surprise medical bills in emergencies, non-elective emergencies and air ambulances,” said Christopher Garmon, PhD, assistant professor of health administration at the Henry W. Bloch School of Management at the University of Missouri – Kansas City.

Currently, the law does not cover ground ambulances, but it created an advisory committee to develop recommendations for charge disclosure, surprise billing protections, and enforcement mechanisms.

People can still choose to be treated by health professionals and off-grid health facilities for elective procedures, but the new law says they must be informed in advance and give their consent.

The No Surprises Act also establishes a procedure on how balancing invoices will be handled between providers and insurers.

The two negotiate the prices and if a solution cannot be found, an independent arbitrator will be engaged to determine a fair refund.

“It’s important to note that the patient is completely out of the middle,” Garmon said.

In September, a new rule from the Biden administration providing more details on how off-grid balance bills are to be paid under the No Surprises Act drew much criticism, especially among groups of doctors and doctors. ‘hospitals.

As a rule, when a dispute is submitted to arbitration, the arbitrator must assume that the amount of the eligible payment (defined as the network median rate for similar services provided in an area) is what it is worth paying for -maintenance of the network.

Other factors may also be taken into account, such as health professional experience, type of hospital and complexity of care, but are not given the same weight.

Several professional health organizations, including the American Hospital Association and the American Medical Association, have filed lawsuits, saying the rule gives insurers an unfair advantage.

There are also concerns that the No Surprises Law could lead to higher healthcare premiums.

Garmon said he doesn’t think it’s likely. In fact, the Congressional Budget Office estimates that the No Surprises Act is put in place to reduce premium growth by 0.5% to 1% in most years.

“I think that’s a good, reasonable estimate,” Garmon said.

Hoadley said it could flip both ways, depending on how network negotiations play out in the future.

“When an insurance company negotiates with a group of anesthesiologists, for example, on what their fees should be in the network physicians’ insurance plan, this new set of rules will cast a shadow over that negotiation,” did he declare. “It could lead to lower rates, which would actually help premiums, or higher rates, which could increase premiums. ”

However, he doesn’t expect the impact to be that big anyway.

“We’re probably talking about a 1 percentage point change one way or the other,” he said.

While the No Surprises Act is intended to stop issuing surprise medical bills to patients, if you receive one after January 1, there are steps you can take to address it.

“We expect there to be some of these situations,” Hoadley said. “Insurers, providers and institutions can take some time to understand the new rules and get it right. “

The first step, recommends Hoadley, is to contact your health insurance company.

“When you receive your explanation of benefits, it will tell you how much you are required to pay and how much the policy is paying, then you can compare that with the bill you received from the medical facility and see if you charged yourself more than that. you shouldn’t be, ”he said.

Finally, under the new law, a complaint line and website operated by the Department of Health and Social Services will be set up for people who believe they have wrongly received a surprise medical bill.

The toll-free number for the No Surprises helpline will be 800-985-3059. The line will go live on January 1.


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