EXPLAINER: New federal law targets medical bill surprises - Chicago Tribune

Patients worried about getting hit with an unexpected bill after emergency care gained a layer of protection as of Jan. 1 from a new federal law.

The No Surprises Act prevents doctors or hospitals in many situations from billing insured patients higher rates because the care providers are not in their insurer’s coverage network.

The law won’t eliminate billing surprises. But it is expected to ease concerns, especially in emergencies where patients may not have time to choose an in-network doctor. A closer look at the law:

Providers outside those networks often bill patients for the difference between what they charged and what the insurer covered. Insurers also may cover less of the remaining bill after the patient pays a deductible, which is the amount paid for care before most coverage starts.

The new law ends these billing surprises for most emergency care by essentially requiring that patients receive in-network coverage with no additional billing from the provider.

It also offers protection in care that isn’t an emergency when people are treated at in-network hospitals by a provider outside their network. That can include radiology, lab work or care from an anesthesiologist.

Emergency departments are expensive places to seek care, and insurers have been trying to limit their use to only life-threatening emergencies.

They have denied coverage if they deem patient visits to be not emergencies. Doctors worry this practice will deter patients from seeking life-saving care when they need it.

Regulations behind the new law note that insurers cannot deny a claim solely based on a doctor’s diagnosis. They also must consider the symptoms patients had when they arrived.

That means insurers should not deny a claim to a patient who rushed to the ER thinking she was having a heart attack but ultimately was diagnosed with heart burn.

In some cases that aren’t emergencies, a doctor outside the network may ask a patient to waive their protections from the law. In exchange, they will provide an estimate of what the care will cost.

Patients have to sign this waiver before the care. If the final bill comes in at least $400 higher than the estimate, patients have a roughly four-month window in which they can dispute the amount.

“This law does not mean (patients) can sit back ... and not be engaged when it comes to where they’re getting their health care,” said Emily Bremer, a St. Louis-area insurance broker.

“This isn’t necessarily going to protect people from big bills, but it is going to protect them from undiscounted bills,” said Karen Pollitz, a senior fellow at the Kaiser Family Foundation, which studies health care issues.

Shoppers often focus on the premium, or cost of coverage, when they choose a plan and may not pay close attention to out-of-pocket expenses like deductibles. A high deductible can lead to a bill of several thousand dollars.

“Maybe now more consumers will understand the limitations of their insurance,” said Laura Wooster, a senior vice president with the American College of Emergency Physicians.

Pollitz recommends comparing any bill with an explanation of benefits sent by the insurer. That should give patients a sense of whether the bill was processed properly.

source: https://www.chicagotribune.com/business/ct-biz-us-med-surprise-medical-bill-law-explainer-20220131-o35sz64ccfeqpg5t22r3na675i-story.html

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