Consumers feel ambushed by surprise medical bills, despite law

Consumers feel ambushed by surprise medical bills, despite law

By John Rossheim | NerdWallet

The no-surprises law, billed as protecting patients from surprise medical bills, went into effect on New Year’s Day 2022. But did the federal law actually reduce health care costs to rates out-of-network charges, as well as certain forms of invoicing” for the part of the supplier’s costs not covered by insurance?

The provisional assessment of the new law is decidedly mixed.

Health insurers report the number of surprise bills the law prevents, but worry about the potential burden of claims litigation.

Analysts believe the law is written to provide substantial consumer protections, but they have yet to see sufficient data to judge compliance.

Health care consumers give a lower rating, according to a June poll by Morning Consult. One in five respondents said they received an unexpected medical bill in the first half of the year, the survey found. But it’s unclear how many of those surprises — if any — should have been blocked by the limited protections of the No Surprises Act.

“It is very difficult to determine whether the law is actually implemented because the problem is this: are consumers not receiving surprise bills?

Field expert

Patricia Kelmar | director of healthcare campaigns at US PIRG

The law prevented more than 2 million potential surprise bills from reaching commercially insured patients from January 1 through February, according to a statement from AHIP, an insurance industry trade group. But analysts still have doubts.

“It is very difficult to determine whether the law is actually implemented, because the problem is this: consumers not receiving surprise bills,” says Patricia Kelmar, director of healthcare campaigns at US Public Interest Research Groups, a national federation of consumer advocacy organizations.

Observers’ doubts about the law’s effectiveness are compounded by low consumer awareness of the new protections. In June, only 16% of adults said they had seen, read or heard something about the law without surprise, according to the Morning Consult poll. Consumers who don’t know the law also don’t know their rights if providers and insurers don’t comply.

The complexity of the law — primarily in the form of exceptions that allow off-network charges and balanced billing in certain circumstances — raises further questions. “Anything that patients think is a surprise bill is not NSA’s business,” says Loren Adler, associate director of the University of Southern California-Brookings Schaeffer Initiative for Health Policy. Emergency care, for example, does not benefit from the protections of the law for emergency care.

Does the new law work?

It may be too early to assess the effectiveness of new consumer protections, and federal agencies do not publish statistics. The Centers for Medicare & Medicaid Services, or CMS, and the Department of Health and Human Services did not respond to requests for consumer complaint data about unsurprising violations of the law.

“It’s a little hard to know, but I guess mistakes are made from time to time,” says Karen Pollitz, senior researcher and co-director of the patient and consumer protection program at KFF, a news site and health care policy. organization. “If a mistake is made, it’s up to the consumer to figure out what to do next, and that’s not how it should have worked.”

Other observers are satisfied with the law’s overall performance. “The no-surprises law works pretty well,” Adler says. “It doesn’t solve all the problems in the healthcare system, and there are still a few sources of surprise bills.”

How the law is supposed to protect you

The protections of the No Surprises Act are broadest in the emergency room, where patients are most vulnerable and least able to control whether all of their clinicians are part of their insurer’s network.

“Most unexpected medical bills will involve emergency services,” Pollitz says. “In the emergency room, there are no exceptions. Anyone who touches you or your imagery is obligated to first send their claims directly to your health plan—before they send you a bill—to find out your cost-sharing amount in the network. If they don’t, there’s a $10,000 fine for every time they get it wrong.

Hospitals are also prohibited from billing the balance for post-stabilization care, services provided by any department after a patient has received initial emergency care.

The new law also protects against out-of-network and balanced billing for non-emergency care, but with various exceptions. For example, if your in-network primary care physician orders tests from an out-of-network lab, the lab may still charge you the difference between the in-network and out-of-network rates.

The No Surprises Act offers various consumer protections if you do not use insurance. “If you’re paying out of pocket or don’t have insurance, you have the right to get a good faith estimate up front,” Kelmar says. “It gives consumers a chance to put off and financially plan for medical treatment.”

If you are asked to sign a waiver of your rights under the law with no surprises, think carefully before agreeing to what could be unlimited financial liability. If you sign and later regret it, you can always have recourse. Providers are not permitted to ask patients to waive coverages if no network provider is available, if there are unforeseen urgent medical needs, or for certain ancillary services.

What to do if you receive an unexpected bill

What do you think of a provider charge significantly higher than the network coverage of your package? You might need some help understanding what’s behind the charge. “It could be a mistake, or it could be vendors always trying to profit from sending a balance bill,” says Kelmar.

You can try calling the CMS No Surprises Helpline at 800-985-3059; the service will tell you how to file a dispute or complaint in any state. Support is available in English and other languages. “CMS is supposed to determine who should resolve each complaint,” Pollitz says.

It is important to know that CMS offers two processes for consumers who disagree with supplier invoices:

  • If you use health insurance and think you’re being charged more than your plan’s in-network rate for doctors or services covered by law with no surprises, you can file a complaint.
  • If you are uninsured or have chosen not to use your insurance and the supplier charged more than $400 more than their estimate, you can dispute an invoice.

Under the No Surprises Act, your state has chosen a mode of enforcement:

  • Some states enforce the law themselves.
  • Other states leave enforcement to federal agencies.
  • Still other states work with federal law enforcement agencies.

The No Surprises help desk should be able to tell you how the app works in your state.

Adler suggests a different starting point: “If you receive an unexpected bill from a supplier, your first resort is your insurer; they risk losing their license if they do not comply.

Pollitz suggests yet another avenue: state consumer assistance programs, or other state or federal agencies that offer insurance assistance to consumers. “Consumers should reach out to anyone they think can help them,” she says.

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John Rossheim writes for NerdWallet. E-mail:

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