Some protections are on the way if you have ever been surprised by an out-of-network medical bill.
The No Surprises Act is a consumer protection law. Balance billing is when a person gets medical care by a provider outside of their private insurer's network, even when visiting an in-network facility.
According to the Kaiser Family Foundation, it is a common scenario in emergency room visits. Part of your visit may require ancillary service providers not covered by your insurance, such as anesthesiologists, radiologists and intensivists.
These ancillary services are often in the same building as an in-network provider, which adds to the confusion of what is actually covered through insurance.
She says that patients are not in a good position to police their insurance coverage when they are in an emergency room.
Kelmar says that it isn't like you're given a bunch of offers of who you can choose as a provider. The last thing you should be doing is checking network status and asking for cost estimates.
Surprise billing is already banned under Medicare and Medicaid, but private insurers are subject to the new rules.
Patients shouldn't receive a surprise medical bill from an out-of-network provider in the following scenarios.
When you go to the emergency room.
You can receive care at an in-network facility.
You are transported by air ambulance.
If you are in stable condition, emergency care providers can't charge you out-of-network rates for services rendered, unless you give consent and you can travel on your own to an available in-network provider.
The consumer will no longer be the middleman between their provider and insurer, and will only pay for in-network costs. Insurers and out-of-network medical providers will have to settle any outstanding balance. The law gives insurers and providers 30 days to sort out discrepancies, and there is a new process for them to settle their disputes.
It matters where you are. The new federal protections only apply to emergency rooms and urgent-care centers. Hospitals, hospital outpatient departments, and ambulatory surgery centers that are in-network are some of the places they apply for.
These protections don't apply to non- emergency services provided in other facilities like addiction treatment facilities, birthing centers, clinics, Hospice, nursing homes, or urgent-care centers that aren't licensed to provide emergency services. You will always want to check that these facilities and the services they provide are in-network for urgent-care centers.
Even though you have no control over who provides the service, the No Surprises Act won't cover ground ambulance transportation. You might still get an out-of-network balance bill for an ambulance. Kelmar says to call the ambulance provider and try to negotiate your bill because some states offer surprise bill protections for ground ambulances.
It can be difficult to get a straight answer on what your insurer covers when dealing with a health-care provider. Kelmar suggests asking, "Are you part of my plan's network?" rather than, "Do you take my insurance?" as that will tell you more about what to expect for actual costs.
Surprise Billing Protection Form can be signed by out-of-network doctors. Kelmar recommends that you read it thoroughly, have a full estimate of charges, and be willing to pay the amount that you are told you will pay.
Emergency physicians, facilities, assistant surgeons, anesthesiologists, radiologists, hospitalists and intensivists are not allowed to ask you to sign this form. If you sign this form and it is $400 higher than the estimate, you can file a complaint online or call 1-800-985-3059.
If you get a medical bill after Jan. 1, 2022, contact the provider and insurer. You can file a complaint within 120 days if they insist on payment.
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