Medical bills may continue to take consumers by surprise despite the No Surprises Act.
Earlier this year, President Joseph R. Biden remarked that “millions of hard-working Americans will no longer have to worry about unexpected medical bills.” He was referring to the federal No Surprises Act, which took effect in 2022 and provides consumer protections against unexpected medical bills.
But whether President Biden’s claim will be true is complicated by loopholes in the law and administrative rules, as well as a recent federal court ruling and legal challenges.
People who live in the United States are more worried about surprise medical bills than other health care and household costs. And in the past two years, a third of insured adults said they had received a surprise medical bill. To address this systemic issue, the US Congress enacted the No Surprises Act in late 2020 to address surprise medical bills and provide patient protections.
The No Surprises Act attempts to eliminate unexpected medical bills by requiring private health plans to cover surprise medical bills at network rates. If an insured patient is billed for emergency services, air ambulance services, or care rendered by an out-of-network provider at an in-network hospital or facility, patients are only responsible for what would have been billed to receive care. network services.
The law also prohibits care balance billing by out-of-network providers for emergency services, in-network hospital services, and certain non-emergency services, meaning patients only pay the in-network cost-share amount. . Lawmakers have attempted to ensure that when a patient receives a surprise medical bill, the insurance company and health care provider agree to payment through arbitration, rather than imposing on the patient the task of fight against fees.
While these protections have been hailed as an important first step, some experts are already pointing to the law’s narrow reach and its many shortcomings. For example, the Act’s protections only apply to hospitals. If a surprise bill comes from a doctor’s office, birthing center or most urgent care clinic, the patient may still have to pay.
A surprise bill could also appear if a patient’s doctor orders a test from a laboratory that is not part of the patient’s insurance network. By law, the lab does not have to issue a warning that the patient is taking a test from an out-of-network provider.
Land ambulances are another place where the law may not protect patients. If a patient travels to the hospital in an air ambulance, they are protected, but if the patient travels to the hospital in a land ambulance, the patient may end up with a large medical bill. To avoid a surprise medical bill, patients’ best bet might be to forego treatment in a land ambulance, but that could only delay crucial care until they have reached the hospital by another means. transport.
Once patients are admitted to a hospital, they have certain protections, such as those provided by the surprise billing protection form. If a patient is receiving care in a hospital and a provider recommends that the patient see another provider, the first provider should tell the patient if the new provider is outside the patient’s insurance network. In addition, the Surge Billing Protection form asks providers to estimate the cost of consulting with new providers and to list potential network providers who can provide the same service.
Patients can find a major problem with the surprise billing protection form. Although the provider must provide a good faith estimate of the out-of-network provider cost, the surprise billing protection form also serves as a waiver. Once a patient has signed the form, all the protections of the law without surprises no longer apply.
Because of the form’s waiver feature, the law prohibits certain types of providers (emergency physicians, surgeon assistants, anesthesiologists, and radiologists) from asking patients to sign the form. If one of these types of providers tries to get a patient to sign the protection form, the patient can call a federal hotline designed to receive reports of law violations without surprise. After reporting a potential violation to the hotline, the supplier cannot report the debt to a collection agency while hotline employees or other workers investigate.
And patients who don’t have health insurance — or don’t want to use it — also have increased protections under the law. The law requires any provider to provide a good faith estimate of what they expect to charge the patient. If the actual bill exceeds the Good Faith Estimate by more than $400, the patient pays the Good Faith Estimate and an additional $400, and the provider cannot collect the remainder of the bill.
Despite the shortcomings, some experts and interest groups have unsurprisingly praised the law. But some medical providers are less enthusiastic. Over the past two years, many vendors have filed lawsuits challenging the arbitration process set up by the US Department of Health and Human Services. These costumes have had some success. In a victory for medical providers, a district court recently struck down aspects of the law relating to the independent dispute resolution process.
Even as the Act falls into jeopardy due to legal challenges, affected patients, providers and insurers are only just beginning to understand the Act’s protections and its limitations.