The No Surprises Act Not Foolproof

February 23, 2022, 9:45AM. By Jane Mundy

The No Surprises Act, which went into effect January 1, 2022, is designed to provide consumer protection against surprise medical bills such as emergency room overcharges, out-of-network billing and more. But there are some gray areas.

Santa Clara, CAThe No Surprises Act, that went into effect January 1, 2022 intends to provide protection against surprise medical bills such out-of-network bills for in-network hospitals and services such as an air ambulance ride (not ground ambulance) to an in-network hospital. But don’t be surprised if you get a surprise bill…

Out-Of-Network

The act is mainly designed to curtail unexpected costs due to certain out-of-network health care services. It intends to change emergency air transportation, crucial for patients who live in rural areas; to end balance billing (when a provider charges a patient the remainder of what their insurance does not pay). Patients should no longer be wrongfully billed because they didn’t have the option to choose where to receive care, a situation that happens far too often in emergency rooms. In other words, if you receive emergency care or scheduled treatment from doctors and hospitals that are not in your insurance networks and a hospital you did not choose, you are only responsible for that hospital’s in-network cost-sharing.

And you’re covered when you receive nonemergency services from out-of-network providers (such as a radiologist) at in-network facilities. An out-of-network provider can no longer bill you more than your in-network co-pays, co-insurance, or deductibles for covered services performed at an in-network facility. Say you’re scheduled for a biopsy, a service that your health plan covers. The hospital and surgeon you have chosen are covered by your plan because they are in-network, but the pathologist and the anesthesiologist the hospital uses are out-of-network. Before January 2022 you would have been on the hook for out-of-network charges; with the No Surprises Act the pathologist and the anesthesiologist, and any other out-of-network providers you did not choose to participate in your biopsy will be costed at the in-network rate.

You can still be treated by an out-of-network provider, however, if you have agreed in advance and know the cost will be higher. After this, you must give consent to these higher costs. If you gave consent for the higher cost, you are expected to pay the balance bill and your out-of-network co-insurance, deductibles, and copays.

Two-thirds of people who file for bankruptcy cite medical issues as a key contributor to their financial downfall, either because of high costs for care or time out of work, reported CNBC in 2019. Research indicates an estimated 530,000 families turn to bankruptcy each year because of medical issues and bills, and Emergency Room Overcharges have been a main contributor.

Emergency Room Overcharges

About 1 in 5 emergency room visits and up to 1 in 6 in-network hospitalizations include at least one surprise out-of-network bill, according to the Kaiser Family Foundation. The Department of Health and Human Services (HHS) found that patients can be hit with more than $1,200, on average, for anesthesiologists' services, $2,600 for surgical assistants and $750 for childbirth-related care. “No one should have to worry about going bankrupt after falling ill or seeking critical care," HHS Secretary Xavier Becerra told CNN when the report was published in November.

No Surprises Act – Gray Areas

Like most any rule or regulation or act, it is not ‘black and white’. There is a gray area, wiggle room. So don’t be surprised that the No Surprises Act has a few gray areas – it doesn’t apply to everyone and every situation.  Consumer Reports weighs in:

• The Act may not extend to some tests your in-network doctor might order, won’t apply at all to certain urgent care centers or outpatient facilities and clinics, and at birthing, hospice, or addiction treatment centers.
  It does not protect people with short-term health insurance, which are plans that offer coverage for less than 365 days.
• Urgent care centers may advertise using the word “emergency,” but they may not be licensed by the state to provide actual emergency care similar to what you would receive at a hospital—and thus are not subject to the new law.
• Retail Clinics, usually in drugstores like CVS and Walgreens, that offer certain tests and treatments, may not be covered.

If you believe you have received a surprise medical bill from a provider for the services specified above, contact the U.S. Department of Health and Human Services and file a complaint by calling 800-985-3059 (toll-free) or going to https://www.cms.gov/nosurprises/consumers.

If you have received a surprise bill you believe is not allowed under the new law, you can file an appeal with your insurance company, then ask for an external review of the company’s decision after the initial appeal is completed with your plan.