January 4, 2022
For years, millions of Americans with medical emergencies could receive another nasty surprise: A bill from a doctor whom they did not choose—and who does not accept their insurance. However, a law that went into effect on Saturday, January 1, will make many such bills illegal, reports The New York Times.
The change is the result of bipartisan legislation passed during the Trump Administration and fine-tuned by the Biden Administration. It is a major new consumer protection, covering nearly all emergency medical services, and most routine care.
“I thinkthis is so pro-consumer, it’s so pro-patient — and its effect will eventually be felt by literally everybody who interacts with a health care system,” said Senator Bill Cassidy (R-Louisiana), who was part of a bipartisan group of lawmakers who wrote the bill. He said he counted the bill as among his top achievements as a lawmaker.
Even with insurance, emergency medical care can still be expensive, and patients with high-deductible plans could still face large medical bills. But the law will eliminate the risk that an out-of-network doctor or hospital will send an extra bill. Those bills add up to billions in costs for consumers each year.
“This is such an important consumer victory because it is going to protect consumers from an egregious and pervasive billing practice that has just grown over the years,” said Patricia Kelmar, the health care campaigns director at the consumer group U.S. Public Interest Research Group (PIRG).
Specifically, if you are having a medical emergency and go to an urgent care center or emergency room, you can’t be charged more than the cost sharing you are accustomed to for in-network services. This is where the law’s protections are the simplest and the most obvious for people with health insurance.
You will still be responsible for things like a deductible or a copayment. But once patients make that normal payment, they should expect no more bills.
“We shouldn’t have to depend on people knowing minutia about insurance regulation in order for them to get care or not be unfairly billed,” said Anthony Wright, the executive director of Health Access California, a patient group that supported the federal law and that fought for a law that banned surprise bills in California starting in 2017.
Several studies found that around 20% of U.S. patients who had emergency care were treated by someone outside their insurance network, including emergency room doctors, radiologists or laboratories. Any of those providers could send patients an extra bill after the fact, and some medical groups did so routinely. Such bills are now illegal.
There is one important exception.
The new law does not prevent ambulance companies from billing you directly for their services if they travel on roads. It does offer protections against surprise bills from air ambulances.
Ground ambulances were left out of the recent legislation because legislators determined they would need a different regulatory approach. Congress established a commission to study the issue and may consider reforms.
Eleven states prevent ambulances from sending out-of-network medical bills. Patients who live in the other states are quite likely to get a bill in the mail if they require an ambulance. Research shows as many as half of people who need an ambulance receive such a bill, though the amount is not always large.
Behind the scenes, medical providers are still fighting with regulators over how they will be paid when they provide out-of-network care. But those disputes will not interfere with the law’s key consumer protections.
Finally, for scheduled services, like knee operations, C-sections, or colonoscopies, it’s important you choose a facility and a main doctor that is in your insurance plan’s network. If you do that, the law bars anyone else who treats you from sending you a surprise bill. This also addresses a large problem. Surprise bills from anesthesiologists, radiologists, pathologists, assistant surgeons, and laboratories were common before.
If, for some reason, you are having such a service and you really want an out-of-network doctor to be part of your care, that doctor typically needs to notify you at least three days before your procedure and offer a “good faith estimate” of how much you will be charged. If you sign a form agreeing to pay extra, you could get additional bills. But the hospital or clinic can’t force you to sign such a form as a condition of your care, and the form should include other choices of doctors who will accept your insurance.
“People should really, really think carefully before they sign that form, because they will waive all of their protections,” Kelmar said. She recommended that patients skip right to the part of the form that lists covered alternatives.
Research contact: @nytimes