Federal legislation that took effect Jan. 1 now protects many Americans from receiving surprise medical bills.
The ‘No Surprises Act’ came into effect earlier this year to help prevent situations like a State College patient who was charged more than $2,000 for blood tests performed at a hospital from the network by a network in- doctor but sent for analysis in a laboratory outside the network.
Another Lancaster consumer had surgery at an in-network hospital performed by an in-network surgeon, but an out-of-network anesthetist assisted in the procedure, resulting in a $1,300 bill.
A Scranton consumer had a baby at an in-network hospital, delivered by an in-network doctor, but complications led to the baby being seen by an out-of-network neonatologist, resulting in a surprise bill of $750.
These concrete examples of surprise bills are documented in complaints filed with the Pennsylvania Department of Insurance.
“One in 3 Pennsylvanians receives surprise medical bills each year, many seeking emergency care, and most of them don’t know where to turn for help,” says Antoinette Kraus, executive director from the Pennsylvania Health Access Network.
“The No Surprises Act is a game-changer and will allow patients to focus on their care rather than worrying about unexpected bills, even when they’ve done everything right and sought in-network care.”
What is that?
The Consolidated Credits Act 2021 was passed in late December 2020 and contains numerous provisions to help protect consumers from surprise bills, including the No Surprises Act, which came into force this year. Consumers now have new billing protections when they receive emergency care, non-emergency care from out-of-network providers at in-network facilities, and air ambulance services from out-of-network providers.
Thanks to new rules aimed at protecting consumers, excessive disbursements are limited and emergency services must continue to be covered without any prior authorization, whether or not a supplier or facility is in the network. This means fewer headaches when trying to coordinate care from your doctors or a hospital and weighing the costs depending on whether or not they are part of your insurer’s network.
Previously, if consumers had health coverage and received care from an out-of-network provider, their health plan generally did not cover the full out-of-network costs. This left many patients with higher costs than if they had been seen by an in-network provider. This most often happens in an emergency situation where you may not be able to choose who will give you medical care.
Even if you go to an in-network hospital, you may receive care from out-of-network providers at that facility. That’s when the “surprise” bills appear from out-of-network providers who charge you the difference between their fees and the amount your insurance is willing to pay them.
The No Surprises Act protects patients from surprise bills by requiring emergency services to be billed in-network, without the need for prior approval. In addition, certain non-emergency services that you receive at a network facility but are performed by non-network ancillary providers will also be covered as in-network services. In both situations, patients will only be responsible for their in-network cost sharing (such as a deductible or co-pay) for the service.
The legislation also prohibits other out-of-network charges and surprise billing by requiring health care providers to give patients plain language notice explaining that patient consent is required to obtain out-of-network care before the provider can charge the consumer.
Help for Pennsylvanians
More help navigating medical bills comes from an executive order signed by Pennsylvania Governor Tom Wolf. It establishes a way for state residents to resolve bill-related disputes and get answers to questions through the Pennsylvania Department of Insurance. The order designates the Pennsylvania Department of Insurance as the lead agency to coordinate implementation of the law without surprises in the Commonwealth. Now, if you receive a surprise medical bill, you can contact the insurance department to file a complaint and also ask for help from your health insurance.
The No Surprises Act protects consumers with coverage through their employer, Pennie (the Pennsylvania-based marketplace), or through an individual plan. It does not apply to consumers with Medicare, Medicaid, CHIP, or Tricare, as these programs already have balance billing protections. It also does not apply to patients with short-term coverage or other limited benefits. However, these consumers and the uninsured will now be able to get an estimate of medical costs before receiving care, and the law creates a process to dispute any bill that is at least $400 higher than the estimate.
If you have questions or need more information about the No Surprises Act or bill surprises, contact the Pennsylvania Insurance Department at 1-877-881-6388 or visit www.insurance.pa.gov/nosurprises. You can also contact the No Surprises Helpline (NSHD) at 1-800-985-3059 or visit https://www.cms.gov/nosurprises for more information about protections under the law.