When you go to the emergency room after an accident, chances are you will have a doctor that is not in your insurance network taking care of you. When this occurs, it could mean you will get an unexpected medical bill for that doctor’s services. According to the Kaiser Family Foundation, recent studies have found that 1 in 5 emergency room visits and about 1 in 10 elective surgeries resulted in a surprise out-of-network bill. In addition, between 9% and 16% of in-network hospitalizations for non-emergency visits can result in a surprise bill for an out-of-network provider.
In an effort to crack down on this behavior, Congress had passed the No Surprises Act (NSA), which went into effect on January 1, 2022. The new law protects consumers against these surprise medical bills. But what does this all mean, and how can out-of-network providers still get away with the practice?
Surprise billing typically occurs when an insured individual receives care from an out-of-network healthcare provider that they did not choose. According to the Centers for Medicare & Medicaid Services, the consumer will receive a surprise bill when the out-of-network provider bills the consumer for the difference between what the healthcare provider charges and the amount paid by their health insurance.
For example, let’s say you get into a car accident in Washington, DC, and experience severe injuries. You are taken to the nearest emergency room and rushed into surgery. The doctor who performs emergency surgery on you is not part of your health network even though the hospital itself is. A few weeks later, you receive a bill from that doctor to pay for the surgery after your insurance company denied it.
The No Surprises Act was created to prevent the above example from occurring. According to Kaiser, the NSA protects consumers in the following ways:
The NSA also created a process to determine the payment amount for an out-of-network medical bill, including negotiations between the plans and providers and an independent dispute resolution process if talks break down.
The new law will protect consumers for specific types of services, including:
Emergency services – These protections apply to emergency rooms, freestanding emergency departments, and urgent care centers. It also applies to air ambulance transportation services, which can be more expensive yet provide consistent medical treatment. However, ground ambulance services are not included in the law.
Post-emergency stabilization services – Post-emergency stabilized care is a treatment the patient receives after an emergency visit, such as transporting to another healthcare facility using non-medical transport. The NSA requires patients receiving written notice and giving written consent to be transferred to another healthcare facility.
Non-emergency services provided at in-network facilities – Doctors who work in an in-network facility often may not work for that facility. Instead, that doctor, who may not be in your network, will bill the health insurance independently for services rendered. Non-emergency services include treatment, equipment, imaging and lab services, and preoperative and postoperative care.
There is an exception to the No Surprises Act. If a patient has given prior written consent to waive their rights under NSA, they will be billed more by out-of-network providers.
It is crucial to note that the patient must give their consent voluntarily. The healthcare provider cannot ask patients to waive their rights to any emergency or non-emergency services.
In addition, a patient cannot be coerced into waiving their rights, such as delaying necessary treatment or charging cancellation fees for existing appointments. However, providers can refuse care if consent is denied unless there is no in-network option.
Patients can only waive protections for certain non-emergency services. The waiver does not apply to the following services:
It’s important to realize that if an injured victim waives NSA protections, they will receive a surprise bill for medical services rendered. Therefore, you must not sign the waiver before having any medical procedure done.
If you do receive a surprise bill, you do have the opportunity to appeal the decision. It is in your best interest to speak with an attorney to learn what your options are.
For decades, Regan Zambri Long has been protecting the rights of consumers against insurance companies and large corporations. If you are having trouble with your insurance company, it’s best to speak with an experienced Washington, DC attorney to discuss your legal options. Contact us today at 202-960-4596 for a free consultation.