Tucked away deep within the massive 2,123-page Consolidated Appropriations Act passed by Congress late last year , you will find something called the No Surprises Act. After years of debate among health insurance companies, hospitals, doctors, ambulance companies, patient advocates, legislators and others, this act takes on the problem of surprise medical bills — that is, health care provider bills not covered by a patient’s health insurance plan. This happens because a health care provider has provided services but is not a participant in the patient’s health plan provider network.
The stage for surprise medical bills is set by the fact that health insurance plans negotiate rates with a select group of health care providers that are far below the “sticker price” rates these providers assign to their services. (This pricing scheme makes little sense since no one pays these inflated charges. They mostly just serve as a starting point for a negotiation between the provider and a patient without insurance.) In pursuit of profit, health insurance plans require their members to use in-network providers and often won’t pay for services rendered by out-of-network providers.
As an example, let’s say you end up in a hospital emergency room because of a car accident. You are in no position to see which providers are in your health plan network. However, because of your immediate need for care (and because the law requires it), you receive necessary services. This includes an ambulance company, the hospital, a surgeon, an anesthesiologist, a pulmonologist, an oxygen supplier, a physical therapist, etc. Some of these providers may be a part of your health plan network, but some are not. The result is a stack of very large sticker price bills from the out-of-network providers, who will soon be on your doorstep demanding payment. If you’re persistent, you might be able to get the providers to reduce their charges and give you time to pay. If not, your accounts will be turned over to a collection agency, your credit score will be trashed, your car may get repossessed, and you’ll probably be off to see a bankruptcy lawyer.
Although the No Secrets Act is lengthy and complicated, the basic thrust of it is this. If you receive services from a health care provider not a part of your health plan’s provider network, you will only be required to pay what you would have been charged if the provider was in the network. So, you’ll be responsible for your normal co-pay or deductible, but no more.
The act then creates an arbitration-like process whereby your health insurance plan and your out-of-network health care provider duke it out to determine what the provider will be paid. You, however, are out of the middle of this dispute (although health insurance companies argue this system is going to increase costs and result in higher premiums).
The No Surprises Act doesn’t go into effect until Jan. 1 of next year. Thus, you are best advised to avoid the need for emergency medical services until that time.
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January 31, 2021 at 02:00PM
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Money & the Law: Act targets surprise, out-of-network medical bills - Colorado Springs Gazette
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