“Surprise medical bills” are never a good surprise. They happen when you can’t control who provides your medical care – like when you have emergency care or when your hospital chooses which doctors see you during your admission. You may have chosen an in-network hospital for your knee surgery, but your hospital might contract with an anesthesiologist who is (unknown to you) out of your network. This has resulted in shockingly high bills for out-of-network care where your insurance covers little or nothing. (Within the medical industry, “surprise billing” is called “balance billing.”) Congress passed the No Surprises Act that took effect in 2022 to prohibit surprise billing to patients with group or individual health insurance. Some health insurance programs already had protections against surprise medical bills. If you have coverage through Medicare, Medicaid, TRICARE, Indian Health Services, or the VA, you were already protected against surprise bills even before the No Surprises Act.
What medical services are covered by the No Surprises Act?
1. Emergency Services, including hospital emergency rooms, freestanding ERs, and urgent care centers that are licensed to provide emergency care. Emergency care includes screening and stabilizing treatment sought by patients who believe they are experiencing a medical emergency or active labor. Oddly, the law applies to air ambulance transit, but not to ground ambulance transportation. The federal government estimates there are 39.7 million emergency visits annually by patients with insurance. Of these, 18% will involve at least one out-of-network claim.
2. Post-emergency stabilization services – This includes post-stabilization services in a hospital following an emergency visit. Post-stabilization care is covered until a physician determines the patient can travel safely to another in-network facility using non-medical transport, that such a facility is available and will accept the patient, and that the transfer will not cause other unreasonable burdens. The federal government estimates each year 4.1 million emergency department visits result in a hospital admission, and that 16% of these admissions will involve at least one out-of-network claim.
3. Non-emergency services provided at in-network facilities – This addresses the situation where an in-network hospital contracts with out-of-network doctors. The federal government estimates that 16% of the 11.1 million in-network non-emergency facility stays for privately insured patients each year involve at least one out-of-network claim.
What are the new protections under the new Act?
· Surprise medical bills are outright banned for most emergency services.
· You can’t be charged more than in-network cost sharing (like copays) for covered emergency and non-emergency services.
· It bans out-of-network charges for certain additional services (like anesthesiology or radiology) from out-of-network providers as part of your visit to an in-network facility.
· Health care providers and facilities must give you an easy-to-understand notice explaining billing protections, who to contact if you have concerns, and that patient consent is required to waive billing protections.
Yes, you can be asked to waive the protections of the No Surprises Act, but it must be in advance, and it must not be in emergency situations or in a hospital where there is no in-network provider in the facility that could provide your care. For example, if you have a health insurance plan that covers only the Duke Health but you want a non-emergency second opinion from a doctor at UNC Ortho or at Emerge Ortho for your shoulder pain, UNC Ortho or Emerge Ortho may ask you in advance to waive your protections so they can bill at out-of-network rates. You don’t have to waive your protections in that situation, but UNC or Emerge may then refuse to see you.
If you receive a surprise medical bill, exercise all your appeal rights with the insurance company and contact the medical provider to express your concerns. Call the toll-free number for the “No Surprises Help Desk,” which is 1-800-985-3059 for more assistance.
Kim K. Steffan is an attorney with Steffan & Associates, P.C. in Hillsborough, NC. She can be reached at (919) 732-7300 or firstname.lastname@example.org.