“…nearly one in five patients who go to the emergency room, have an elective surgery, or give birth in a hospital receive surprise bills, with average costs ranging from $750 to $2,600 per episode.” (HHS.gov)
My first pregnancy was blissfully uneventful – until the final routine doctor visit at 39 weeks of pregnancy.
After much squeezing, pressing, and poking with an ultrasound wand, the doctor informed me that my baby was “breech”. Instead of the normal head down position, my baby was head up.
Breech position isn’t ideal for either the mother OR the baby. Especially when the mother will soon go into labor.
I was immediately scheduled to be at the hospital at 5 am the following morning for an ‘external version procedure’. That’s a fancy name for pushing on a pregnant woman’s belly to try to turn the fetus to a head down position. Unfortunately, I am petite and my baby was full-term. That baby had zero room to hiccup much less do a 180 in utero.
Next up: caesarean section!
The good news is, despite the last-minute drama, my beautiful baby boy was born healthy and thriving.
After we were discharged from the hospital, we soon settled into our new, joyous family routine.
And then the bills started coming. From the doctor’s practice for the caesarian section. From the hospital. From the anesthesiologist. From the lab. From the doctor for the external version procedure. And the bills just kept coming…
A recent report from the U.S. Department of Health and Human Services (HHS) ASPE office showed that surprise billing is common if you have private insurance—”nearly one in five patients who go to the emergency room, have an elective surgery, or give birth in a hospital receive surprise bills, with average costs ranging from $750 to $2,600 per episode.” (HHS.gov)
What happens when you get a bill you DON’T expect? Or you receive a bill for an emergency procedure you had that was “out-of-network”? What do you do?
The No Surprises Act
This is where the 2022 No Surprise Act comes in. The No Surprises Act “protects people covered under group and individual health plans from receiving surprise medical bills when they receive most emergency services, non-emergency services from out-of-network providers at in-network facilities, and services from out-of-network air ambulance service providers.” The bill gives protections for those with and without insurance. It also provides paths for bill disputes and good faith estimates.
The No Surprises Act was signed into law as part of the Consolidated Appropriations Act of 2021 by the United Stated congress and went into effect January 1, 2022. The No Surprises Act addresses surprise medical billing at the federal level. The No Surprises Act supplements any existing state medical billing protections and does not replace state protections.
What does The No Surprises Act Cover?
The No Surprises Act includes:
- Ban surprise bills for emergency services, even if you get them out-of-network and without approval beforehand (prior authorization).
- Ban out-of-network cost-sharing (like coinsurance or copayments) for all emergency and some non-emergency services. You can’t be charged more than in-network cost-sharing for these services, and any cost-sharing you pay counts towards your deductible and maximum out-of-pocket limits for the policy year.
- Ban out-of-network charges and balance bills for supplemental care (like anesthesiology or radiology) by out-of-network providers who work at certain in-network facilities (like a hospital or ambulatory surgical center).
- Require that health care providers and facilities give you an easy-to-understand notice explaining that getting care out-of-network could be more expensive, and your options to avoid balance bills. You’re not required to sign this notice or get care out-of-network.
- If you don’t have insurance or choose not to use it, these new rules make sure you get a “good faith estimate” of how much your care will cost, before you get care.
- They also allow you to file a dispute if you are charged more than $400 above the estimate.
Source: CMS.gov
Watch this short video for an overview of The No Surprises Act:
How Does The No Surprises Act Help with Medical Bill Disputes?
Let’s say you’re on vacation enjoying a beach far away from your home. It’s hot, it’s sunny, it’s perfect. You set your cold beverage in the sand and stroll into the ocean to cool off. And BAM, a swarm of jellyfish stings you over and over and over.
Suddenly, you have a bill from a hospital emergency room visit. The bill is $3000, but your private insurance will only pay $1000 because the emergency room was far away from your home and out-of-network. Are you stuck paying the $2000 difference?
The No Surprises Act provides an independent dispute resolution process known as an IDR. The IDR process is used to “determine out-of-network payment amounts between providers (including air ambulance providers) or facilities and health plans.” (cms.gov)
If you have tried to negotiate with the insurance company, medical facility, or medical provider with no success, you may be eligible to use The No Surprises Act independent resolution process. A detailed explanation and steps of The No Surprises Act independent dispute resolution may be downloaded here. To initiate an independent dispute resolution (IDR) case, click here.
How Does The No Surprises Act Help You?
Whether you have private insurance, are uninsured, or are a self-pay health care consumer, The No Surprises Act can protect you from paying too much for medical bills. Emergency services cannot charge surprise bills or out-of-network fees regardless of where you seek treatment. Supplemental care offered at in-network facilities may not charge out-of-network fees. You may get a “good faith estimate” if you don’t have insurance or choose not to use it. There is a dispute pathway if your bill is over $400 more than the estimate.
As a healthcare consumer, The No Surprises Act requires that the notice and consent forms you are asked to sign are clear and easy to understand. If you have questions, ask a healthcare professional to help you understand or ask a friend or family member to read through the paperwork with you. Remember that signing these forms MAY waive your rights under The No Surprises Act. You must educate yourself to make sure you keep the protections available to you.
How a Patient Advocate Can Help
Seeing a healthcare provider can be intimidating at the best of times. Emergency situations can be frightening. Having a trusted friend or family member to advocate on your behalf can make a difference in the kind of care one receives.
Watching a relative or close friend be overwhelmed by a mountain of medical paperwork during a tense medical situation is painful. It’s difficult to make rational financial decisions during those times. A patient advocate can help you stay calm and make the best decisions possible. And that patient advocate can be anyone close to you like a relative or neighbor. Anyone can help their loved one by understanding and advocating for their healthcare wishes.
Advocating for you loved one can also help them financially. Using the information about The No Surprises act could save your loved hundreds or thousands of dollars. You can help protect your loved one from being the victim of surprise medical bills.
Are you ready to make a difference in your loved one’s life?
Learn more about how to help your loved one with the How to Advocate for Your Loved One online course.
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