Wed, March 16, 2022 (Kaiser News) — Patients no longer have to pay for out-of-network care provided without their consent when they are treated at their covered hospitals. Health insurance Since a federal law took effect earlier this year.
But legal protections against the scourge of outrageous, expensive unexpected medical bills may be as good as the level of patient knowledge and ability to ensure those protections are enforced.
Here’s what you need to know.
No Accidents Act Compliant.
Research shows that about one in five emergency room visits results in unexpected bills.
Unexpected bills often come from emergency room doctors and anesthesiologists, as well as other specialists — who are often not covered by a patient’s insurance network and not chosen by the patient.
Before the law went into effect, the problem was this: Suppose you needed surgery.You have chosen an in-network hospital – that accepts your health plan And a price has been negotiated with your insurance company.
But one of the doctors treating you did not have insurance for you. surprise! You get a large bill, separate from the bills from the hospital and other doctors. If your insurance company doesn’t deny the claim outright, your insurance company isn’t covering most of the cost. You should pay the balance.
The new law, known as the “No Surprise Act,” broadly states that patients seeking care from in-network hospitals cannot be charged more than the negotiated in-network rates for any out-of-network services they receive there.
The law says insurers and health care providers must figure out how to pay their bills and not leave patients with unexpected bills that their insurance doesn’t cover.
But the law provides leeway for suppliers who want to try to circumvent the protections.
Warning: The law leaves out a huge amount of medical care.
These changes come with a lot of caveats.
While the legal protections apply to hospitals, they do not apply to many other places, such as doctors’ offices, birthing centers, or most urgent care clinics. Air ambulances are often the source of high bills outside the network and are protected by law. But ground ambulances are not.
Patients need to be vigilant to avoid pitfalls that remain, said Patricia Kelmar, director of health care campaigns for the nonprofit Public Interest Research Group, which lobbied for the law.
Let’s say you go for your annual checkup and your doctor wants to get tested. Conveniently, there is a laboratory directly below the hall.
But the lab may not be in the network – although you share the office space with the doctors who are in the network. Even if the new law goes into effect, the lab doesn’t have to warn you that it’s off the grid.
Watch out for the Accidental Bill Protection Form.
Out-of-network providers may provide patients with a form explaining their protection against unexpected bills, labeled “Accidental Bill Protection Form.”
Signing it up gives up those protections and instead agrees to treatment at an out-of-network price.
“The form title should be something like When I sign this form, I waive all my surprise bill protectionbecause that’s what it is,” Kelmar said.
You must give your consent at least 72 hours before receiving care, or at least three hours if services are scheduled on the same day. If you’ve waited weeks for your surgery appointment with a specialist, 72 hours may not be enough to cancel your surgery.
Among other things, the form should include a “good faith estimate” of the fees you will be charged. For non-urgent care, the form should include the names of in-network providers that you can see.
It should also inform you of an unfortunate Rule 22: If you refuse to waive your protection, the provider can refuse to treat you.
It is illegal for some providers to give you this form. These include emergency room physicians, anesthesiologists, radiologists, assistant surgeons, and residents.
Keep an eye on costs. Many patients reported that they were simply given an iPad to record their signatures in emergency rooms and doctors’ offices. Keep looking at the form behind the signature so you know exactly what you’re signing.
If you find a problem, don’t sign, Kelmar said. However, if you find yourself in a difficult situation – for example, because you received this form and are in dire need of care – you can fight back by:
- Write that you “signed under duress” on the form and note the problem (eg, “This form will not be produced by emergency medical facilities”).
- Take a photo of the form and attach your notes. Also consider using this form to shoot your own video describing how it violates federal law.
- report! There is a federal hotline (1-800-985-3059) and a website for reporting all violations of the new law, barring unexpected bills. Both the hotline and the website can help patients figure out what to do, as well as collect complaints.
Speaking of that “good faith estimate”…
The new “Good Faith Estimate” benefit applies wherever you receive medical care.
After your appointment, the provider must give you advance notice of the costs you may have to pay without insurance (in other words, if you do not have insurance or choose not to use insurance). Your final bill may not exceed the estimated $400 per provider.
In theory, this gives patients the opportunity to reduce costs by shopping around or choosing not to pay for insurance.Particularly attractive to high-risk patientsdeductible Insurance plans, but not limited to: so-called out-of-pocket care prices may be cheaper than paying with insurance.
Also: it doesn’t hurt to ask if it’s an all-inclusive price, not just a base price where other side services can be added.
It’s not enough to just ask, “Do you buy my insurance?”
Whether or not medical care is included is still up to the patient. Before you find yourself in a treatment room, ask if the provider accepts your insurance — and be specific.
Kelmar said the question to ask is, “Are you in my insurance plan’s network?” Provide the plan name or group number on your insurance card.
The reality is that your insurance company — Blue Cross Blue Shield, Cigna, etc. — has many different plans, each with its own network. One network might cover a certain provider; another might not.
Keep an eye on your mailbox.
To make sure no one charges you more than you expect, keep an eye on your mail. Hospital visits, in particular, generate a lot of paperwork. Any bills should be itemized in a statement from your insurance company called Description of Benefits or EOB.
Did you notice anything? Make a few phone calls before paying — to your insurance company, provider, and of course, the new federal hotline: 1-800-985-3059.