How to avoid surprise medical bills… and the pitfalls of the new law

Patients are no longer required to pay for medical care received outside their health plan’s network without their consent, when treated at hospitals that are within its coverage. This has been the case since a federal law went into effect earlier this year.

But the law’s protections against the exasperating costs of these surprise medical bills…come with surprises. This is what you need to know.

Studies have shown that approximately one in 5 emergency room visits results in a surprise bill.

Frequently, these bills come from emergency room physicians and anesthesiologists, among other specialists who are often out of the patient’s insurance network, and whom the patient does not choose.

Before the law went into effect, the problem went something like this: Let’s say you needed surgery. You chose a hospital within the network, that is, one that accepts your health plan and negotiates prices with your insurer.

But one of the doctors who treated you does not receive your insurance. SURPRISE! You have a large bill, in addition to bills from the hospital and other doctors. Your insurer didn’t cover much of it, if not they refused to pay the claim in full. You were expected to pay the balance.

The new law, known as the No Surprises Act, provides, in general terms, that patients seeking care at a hospital that is within its coverage network cannot be billed more than the network negotiated rate for any out-of-network service they receive there.

Instead of leaving the patient with an unexpected bill that insurance won’t cover, the law says the insurer and health care provider must determine how that bill is paid.

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But the law creates a large room for maneuver for providers who want to circumvent it.

While the law’s protections apply to hospitals, they don’t apply to many other places, such as doctors’ offices, birthing centers, or most urgent care clinics. Air ambulances, often a source of exorbitant out-of-network bills, are covered by the law. But ground ambulances don’t.

Patients should be vigilant to avoid other pitfalls, said Patricia Kelmar, director of health care campaigns for the nonprofit Public Interest Research Group, which advocated for the law.

Let’s say you go for your annual checkup and your doctor wants to run tests. Conveniently, there’s a lab just down the hall.

But the lab may be out of network, despite sharing office space with your doctor. Even with the new law in place, that lab doesn’t have to warn you that it’s out of network.

Out-of-network providers may give patients a form about their protections against unexpected bills, called a “Surprise Billing Protection Form.”

But by signing it, you waive those protections, and you also consent to being charged for your treatment at out-of-network rates.

Among other things, the form must have a “good faith estimate” of what you will be charged. Even offer a list of alternative providers.

It must also inform you of the unfortunate thing: the provider may tell you that they will not treat you if you refuse to waive your protections.

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It is against the law for some providers to give you this form. These include emergency room physicians, anesthesiologists, radiologists, and assistant surgeons.

You must be very attentive. Many patients report that they are simply given an iPad to record their signature in ERs and doctor’s offices. Insist on seeing the form behind the signature so you know exactly what you are signing.

If you sense there’s a problem, don’t sign, Kelmar said. But if you’re in a bind, say because you get this form and need urgent care, there are ways you can fight back:

  • Write on the form that you are “signing under duress” and note the problem (for example, “Emergency medicine centers cannot file this form”).
  • Take a photo of the form with your notes. Also consider recording a video of yourself using the form, describing how it violates federal law.
  • Make a complaint! There is a federal hotline (1-800-985-3059) and a website to report all violations of the new law, except surprise bills. Both the hotline and the website help patients decide what to do.

The new “good faith estimate” benefit applies anywhere you receive medical care.

Once you make an appointment, the provider should let you know in advance what you could expect to pay without insurance (in other words, if you don’t have insurance or choose not to use it). Your final bill cannot exceed the estimate by more than $400 per provider.

Theoretically, this gives patients the opportunity to lower their costs by comparing or choosing not to pay with insurance. It’s particularly attractive to patients with high-deductible plans, but not exclusively: the cash price of care can be cheaper than paying with insurance.

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Also: It wouldn’t hurt to ask if this is an all-inclusive price, not just a base price to which other services can eventually be added.

It is not enough to ask: “Do you accept my insurance?”.

It is still up to the patients to determine if the medical care is covered. Before an appointment or procedure, ask if the provider accepts your insurance and be specific.

Kelmar said the question to ask is, “Are you in my plan’s network?”, giving the group and plan number.

The reality is that your insurer (Blue Cross Blue Shield, Cigna, etc.) has many different plans, each with their own network. A network may cover a certain provider; and another does not.

check your correspondence

To make sure no one bills you more than expected, pay attention to your mail. Hospital visits, in particular, can generate a lot of paperwork. Anything billed should be itemized on a statement from your insurer called an explanation of benefits, or EOB.

Do you notice something out of place? Make a few calls before you pay: to your insurer, the provider, and of course the new federal hotline: 1-800-985-3059.

Dan Weissmann is the host of “An Arm and a Leg,” a podcast about health care costs.

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