A new law means it’s never been easier to avoid the aggravation and expense of a surprise medical bill.
So, problem solved?
Not quite.
The federal No Surprises Act that took effect this year prohibits sticking unsuspecting patients in certain circumstances with hundreds or thousands of dollars in costs.
But those medical bills will only go away if all hospitals, doctors and insurance companies do exactly what’s required, says Karen Pollitz, a senior fellow at the California-based Kaiser Family Foundation.
And since mistakes can still happen, Pollitz advises that people learn enough about the No Surprises Act to be able to spot them in their medical bills. “People often feel flummoxed by medical bills and insurance claims,” she said.
There still are plenty of scenarios not covered by the law that can generate surprising bills. So, it can pay for consumers to understand potential spending that’s just baked into their coverage.
For instance, Pollitz notes that most people with private insurance have high deductibles, often $1,000 or more. “They go to the doctor … and they just didn’t realize how one procedure could swallow the deductible,” she said.
Congress passed the No Surprises Act amid growing concerns that consumers were getting socked with big bills for out-of-network medical services that they couldn’t reasonably have avoided.
Patients would go to an in-network surgery center or hospital for a procedure and later learn that an anesthesiologist or radiologist or pathologist they’d never met was part of the care team.
When those doctors were out-of-network with the patient’s health plan, there could be disputes between the insurer and the physician about what reimbursement was adequate.
People would then be hit with bills demanding payment for the difference, a practice called “balance billing.” It also occurred following visits to out-of-network emergency rooms, as well.
“There are all these other doctors who work in these facilities and you might not even see their faces or know their names until the bill comes,” Pollitz said. “You could end up owing hundreds or thousands of dollars to those doctors just because you accidentally went out of network — and you didn’t even know because you don’t get to pick them. Those are surprise medical bills.”
Minnesota was one of 33 states that had at least some protections against balance billing before the federal law. A report from the Commonwealth Fund found one key gap in the state statute, since protections did not apply to “self-insured” health plans.
The Minnesota Department of Health estimates that in 2019 about 40% of state residents were in self-insured health plans, which are particularly common among large employers.
The No Surprises Act limits what people must pay for covered services when they inadvertently receive care from certain out-of-network health care providers. In those situations, the law says patients should only be required to pay what their health plan would require with in-network care.
People in employer-sponsored health plans or those with comprehensive insurance for individuals have protections through the act. It applies when those consumers seek emergency room and air ambulance services as well as non-emergency care at in-network hospitals and surgery centers.
Under the law, patients should receive an explanation-of-benefits document from their health plan showing the applicable in-network “cost-sharing” amount that they owe. Insurers must share this information with out-of-network health care providers as well.
Out-of-network health care providers face fines that could reach $10,000 per violation if they bill patients for more than the in-network cost sharing.
The legislation creates a federal website for information and billing complaints as well as a toll free hotline at 800-985-3059.
“If you have a concern about a claim related to emergency services — how it was covered or a bill that you got for emergency services — or for non-emergency services that you got at an in-network facility, you can just go to this website or call,” Pollitz said.
The law requires health care providers to inform patients of their new rights — so watch for more paper when you go to the doctor, says David Glaser, a health law attorney with Fredrikson & Byron in Minneapolis.
Over the past decade, some health insurers have experimented with policies to deny payment for ER visits after-the-fact when carriers see the diagnosis and determine a patient didn’t really need emergency care. The No Surprises Act puts new limits on any such policies.
“What this regulation says is: Wait a minute,” Glaser said. “You can’t focus exclusively on the outcome — you have to look at the signs and symptoms and whether a reasonable person walking into the emergency room might have thought that they had an emergency. And so, if a person wouldn’t know — is this heartburn, or is this a heart attack? — insurers still have to cover those visits.”
A report published in May by two leading health insurance groups estimates the law may have prevented more than 2 million surprise bills just in the first two months of 2022.
Even so, the statute’s reach is limited.
Ground ambulances aren’t covered by the No Surprises Act. The law generally doesn’t apply to physician office services, Pollitz said, or when clinics order tests from out-of-network labs.
People with Medicare and Medicaid coverage aren’t protected by the No Surprises Act, although those programs have their own safeguards, Pollitz said.
Even with the law, patients still can face shocking out-of-pocket costs if insurers decide they won’t cover a service, said Jonathon Hess, the chief executive of St. Paul-based Athos Health, a St. Paul-based group that helps consumers challenge medical bills.
“The denial — that’s the big one,” Hess said. “If you have insurance, you go to an in-network facility and your service gets denied, you could still end up with a big bill.”
And consumers may well confront more expensive surprises when they go out-of-network for non-emergency services.
“That’s a mistake many a person has made — you just didn’t think to ask,” Glaser said.