Health insurance in the United States is a large financial burden on families and individuals. With the number of costs that go into securing and utilizing a health insurance program, it can come as quite a shock that health facilities often send surprise bills after treatment or hospital stays. Surprise bills occur when patients unknowingly receive care from an out-of-network provider and are charged out-of-network costs. Research shows that 1 in 5 emergency room visits results in surprise billing and that up to 16% of non-emergency care results in the same. This issue has been at the forefront of Americans' minds for a long time with numerous attempts from healthcare activists to overturn this ability, and finally-a bill is here. As of January 1, 2022, the federal government signed into law the No Surprises Act, protecting Americans from unexpected payments.
Why Are People Receiving Suprise Bills?
There are a few different ways that health providers are able to legally bill patients amounts beyond what was originally estimated at the cost of treatment. For insurance costs to be fully covered, treatment must be done by an in-network provider. The most common scenario for surprise billing is when patients receive care from an out-of-network provider, even if the healthcare facility is considered in-network. This can happen if the specific practitioner, such as an anesthesiologist or a specialist, is a visiting doctor that is out of network.
Typically, the hospital or care center will provide the pre-determined bill at the time of or shortly after patients receive care. If there is a discrepancy between that bill and the out-of-network provider's rates, the out-of-network provider will send a bill, later on, to make up for the difference. Unfortunately, most patients are not told at the time of care that the provider is out of network or that they will be expected to pay more than the in-network costs. These scenarios are extremely common and put patients who were seeking the care they have the right to under their insurance in a difficult financial responsibility.
Surprise bills can also arise if complications happen during treatment that requires the care of an out-of-network specialist last minute. Whether it's during emergency surgery or a routine procedure, there are times when patients are not able to give permission for care, and professionals have to make their best judgment. But, if you did not consent to the care-it can be quite shocking when the bill arrives and still falls under your responsibility.
Protection Under The No Suprise Act
Until this bill came into play, there was little protection against surprise billing unless you were under Medicaid/medicare. The No Suprise Act had made surprising billing virtually obsolete for private healthcare. Under the provisions act, providers must:
- Ban surprise billing on emergency services or services given without the patient's consent
- Bill all emergency services at in-network costs, including co-pays
- Require all services performed by out of network providers and “balance bills” be billed at in-network costs
- Give a full explanation of accurate cost expectations to patients prior to giving them care or treatment
- Provide post-emergency care services at the in-network costs
- All providers must obtain written consent from patients receiving out of network care at least 72 hrs prior to treatment
- Providers are required to give patients receiving care without insurance or who are not using insurance an accurate estimate of the bill for medical items and services.
If these guidelines are not followed by providers, consumers are able to send in a dispute under the Act and are not required to pay until the dispute is settled. As a general guideline, if the bill is $400 or higher than the expected medical bill, a dispute is warranted.
The act has developed standard handling and processing guidelines to ensure the act is upheld. Once a dispute has been submitted, all collection attempts must be paused until there has been a final resolution. Under the No Surprises Act, disputes will be handed off to the “Selected Dispute Entity” and they will communicate with both the healthcare facility, the insurance company, and the out-of-network service provider to come to a solution. The SDR has 30 days to complete the dispute and reach a settlement.
How Will The No Surprises Act Effect Insurance Costs?
The act may reduce overall commercial insurance premiums, some say by as much as 0.5% and 1%. Taking a bigger look at these numbers reveals an overall predicted saving of more than 30 Billion for U.S Insurance consumers. The act is receiving accolades for its ability to protect Americans and needs and create more visibility when it comes to costs and what they are allocated towards.
As much as the act can reduce the cost of insurance itself, healthcare costs may see a small increase. This is mostly due to the increase in administrative fees, and providers increasing their costs in response to the bill. The actual increase has not been predicted, but experts say these fees will likely show up in the next few years. As of right now, the benefit absolutely outweighs the small cost.
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