Note: This is a rough transcript of episode 25 of Health Savings News and has been lightly edited for clarity. It may not be in its final form.
Hello and welcome to Health Savings News, the podcast about healthcare costs in America and how to save money on the often expensive care all kinds of people need. I’m your host, Evan O’Connor, joined by retired doctors Rich Sagall and Mike Woods. How are you guys doing today?
Good to hear. Each episode we discuss healthcare costs in America, offer tips for saving money, and relevant news that affects and reflects the expensive landscape of healthcare in America.
This week’s topic is the No Surprises Act. The law signed in December 2020 and came into effect January 2022 was designed to protect patients from surprise bills for emergency services at out-of-network facilities or for out-of-network providers at in-network facilities. The No Surprises Act filled in many gaps from existing state and federal laws. Since implementation, the No Surprises Act has prevented an average of 1 million potential surprise medical bills every month.
Well, let’s start off with a question: Why do you buy health insurance? Most people would say to cover the cost of their medical care, but if you’ve been listening to the news recently, you probably heard of people being hit with big medical bills even though they had health insurance. Usually these surprise bills are for emergency services where the patient had no choice or say in where they would be seen, who would see them, and what treatments were obtained. But that’s not always the case. If you have private health insurance that has a network and you have met your deductible and have stayed within the network, you expect to pay your co-pay or co-insurance for the insurance company to pay the rest of the bill. This is also true if you have prior authorization to go outside the network. But what if you don’t follow the rules and get a prior authorization or choose a healthcare provider or facility outside your network? Then what happens? Are you stuck with the bill?
Let’s propose a new situation, however. What happens when you get out of network care when it’s not really your choice? There’s a number of situations where this can happen. The most obvious situation is when you seek medical care while you are traveling or an emergency situation such as an accident or a sudden illness where you need to be and/or are taken to the nearest medical facility for the sake of your health. A more subtle situation is when your network facilities and hospitals have out of network services. It’s more common than you would think. Some of these services include laboratory tests, imaging studies, and many of the providers that will see you in that facility. Some of these providers are anesthesiologists, emergency room providers, radiologists, pathologists, or hospitalists who contract with the institution to provide healthcare. In most cases, you’re either unaware of the status of the testing facility or healthcare providers, or you have no option to choose a service or provider in the network.
As Rich described above, in the past these providers or facilities could bill you any costs not paid for by the health insurance company in a process called Balance Billing. So in this case, since you naturally assume that the insurance company was gonna pay the remainder of the cost of your healthcare, the bill from these facilities and the providers will be unexpected and sometimes even if you get an itemized bill, there are a lot of things you may not know. You may not know that you actually received the bill treatment if you were unconscious or under anesthesia at the time. You’re not sure whether you will billed the correct or even a reasonable amount for the services that you received. You may not know how much of your care is going to be covered by the insurance or whether or not the insurance has already fully or partially paid for your care. This unexpected bill from an outer network provider or facility is termed a surprise medical bill. Hence the term the No Surprises Act.
As Evan said, it became effective on January 1st, 2022. The current administration had made multiple additions to the law and released the Requirements Related to Surprise Billing Final Rules law on August 19th, 2022. This law can protect you from these surprise medical bills under certain circumstances that will describe later in the podcast. The law requires that your health plan and the facilities and providers that serve you send you a notice of your rights under the new law, including who to contact if you have concerns that a provider or facility has violated the protections, and for you to know that your consent is required to waive any balance billing procedures. In other words, you must receive a notice of and consent to being balance billed by an out of network provider or institution. Primarily up to the state regulatory agencies to implement and enforce these new consumer protections, including determining what the cost sharing amounts will be settled on during arbitration. And while most states will work with the federal government to enforce the law the federal enforcement may occur in states that lack the authority or fail to substantially enforce the law. Your state may have even had its own law, as Evan said, but it would only now be in effect if it exceeds the protections covered under the No Surprises Act.
The No Surprises Act was created primarily for people with private health insurance plans that have required networks including both employer-based insurance and injured and individual market health plans. It is meant to protect people from the surprise medical bills when receiving care from outta network facilities or from providers in three circumstances. The first is when you receive emergency care without prior authorization, either at an out-of-network facility or from an out-of-network provider, and you are too unstable to be transferred to an in-network facility. This includes post stabilization care, such as an admission to the same facility when you cannot be transported to an in-network facility or you were not able to give consent to be transported to an in-network facility for continued care. The second situation is when you use an air ambulance emergency transport service, ground ambulance services are not mentioned in the law. The last non-covered services are when you receive non-emergency care at an in-network facility, but are tested by or treated by an out-of-network healthcare provider without giving consent to be billed. In these three situations, the law guarantees that first, your costs are limited to in-network cost sharing outlined in your policy including deductibles, co-insurance or co-payments and out-of-pocket maximum maximums. Second, the providers and facilities can only charge you for the median in-network deductibles and overall rates set forth by your health insurance company. And finally, it prohibits them, the providers from billing you for any additional costs above insurance reimbursements. If you have coverage to Medicare, Medicaid, Indian Health Services, Veterans Affairs Healthcare or Tricare, you are usually protected against surprise medical billing. Although you may wanna check your policy to be sure.
The No Surprises Act also includes other provisions beyond just protection against surprise billing. Most of these are the addition of the current administration, but the No Surprises Act includes an appeal process that helps you if you’ve received a surprise bill that you think isn’t allowed under the new law. You can start this process by calling the No Surprises Help Desk. The number is 1-800-985-3059. The office is open from 8:00 AM to 8:00 PM Eastern Standard Time, seven days a week. You can also submit a complaint online. The URL for this method will be posted with the podcast transcript that you can look up later (https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/Enforcements/FileaComplaint). You can also file a complaint with your State Department of Insurance or with the US Department of Health and Human Services. So to prevent being surprised by copays or co-insurance amounts of your own insurance. The No Surprises Act also requires that the group health savings plan and insurers make information available to you about such thing as prescription drugs and their prices and healthcare spending so that you have an idea of what your out-of-pocket costs may be with your own insurance company. So this includes the amount paid by insurance company for outer network care and information on the most frequently dispensed and costliest medication. The No Surprises Acts also requires providers and healthcare f facilities to publicly disclose any patient protections that they have in place against balanced billing and how they will provide for continuity of care when the provider’s network status changes, such as if they change some of the insurances that they accept.
The No Surprises Act includes an independent dispute resolution process that happens if the insurance company and provider and/or facility can’t reach a voluntary agreement about the reimbursement in a 30 day negotiation period. In most situations, you’ll find that the provider and/or facility will accept the insurance reimbursement as payment in full, but this isn’t always true. So occasionally a bill will end up in this appeal process. Now, many factors are considered when the two try to resolve this issue but be assured that one of the things that is not considered is the usual or customary billed charges for that provider or facility or any rates paid in public sector programs such as Medicare or Medicaid. Unfortunately, I read a report today from the Bloomberg Law Report that some of the considerations that are allowed during the negotiation, such as taking into account the median contract network rates, again, not those specific to your policy, the level or training of a provider and how severe your condition is. What this will do is it will allow the providers to get an increased reimbursement rate, which will eventually result in higher premiums and out-of-pocket expenses for patients.
The No Surprises Act can also help those who are uninsured or who are electing to pay for care without using their health insurance. The No Surprises Act requires healthcare facilities and providers to disclose their patient protections against balance billing and to provide a good faith estimate on how much your care will cost before you get that care. That good faith estimate must be provided in writing upon request. It should include an itemized list with specific details and expected charges for the items and services related to your care, but may not include everything and may not include things that doctors can’t anticipate. If you’ve had your care and the bill exceeds $400 more than what their good faith estimate was, there is a way to dispute the charges. You can get that through the Patient Provider Dispute Resolution Process at www.cms.gov/nosurprises/consumers. No spaces in any of that, and you can find more information on the Good Faith estimates in your rights and in those surprises act, which also establishes the resolution process.
Process sounds simple in some aspects and complex than others. Hopefully it will work to eliminate the surprise bills that many people seem to be receiving.
Yep. I wholeheartedly agree. I was very happy that the No Surprises Act was finally passed into law as a way for consumers and our listeners and followers to keep their medical bills down while not affecting the quality of their medical care.
Yeah, I would say just as a person who has spent more of their time as a patient, that the biggest barrier obviously is that it depends a lot on patients reporting, their providers not following the rules which puts a lot on patients who are already under a lot of duress generally.
The last segment of each episode, we suggest some of the culture, art, entertainment, and social causes we’ve been engaged with to each other and our listeners.
I’m in the process of reading a book called How Medicine Works and When It Doesn’t by F. Perry Wilson. I’ve heard him give some talks on medical advances and medical treatment, and this book is like sitting down and having a beer or two with the doctor and getting an inside scoop as to how doctors feel about the practice of medicine patients and the finances. It’s an interesting book, easy read, and he writes very smoothly. I highly recommend it again, How Medicine Works and When it Doesn’t by F. Perry Wilson.
This week I have a podcast called Uncared For. It is a six part podcast series from Lemonada Media and the Commonwealth Fund hosted by SunChin Pak about the maternal healthcare in the United States. Starting by exploring how and why pregnant people are more likely to die in the U.S. than any other wealthy nations and how and why abortion is essential healthcare, the series compares maternal healthcare around the world to our own and tries to reimagine how healthcare is delivered to pregnant people, especially those affected by racism, poverty, and lack of healthcare coverage.
Thank you so much for joining us for this episode of Health Savings News. Please subscribe, rate, and review us on Apple Podcast or wherever you’re listening to the show — it really does help. You can follow @NeedyMeds on Facebook, Instagram, LinkedIn, YouTube, Mastodon, and you can follow @HealthSavingPod on Twitter (for as long as Twitter remains around) for updates specific to this podcast and send questions, comments, and topic suggestions to email@example.com. Our music is composed by Samuel Rulon Miller. His music can be found at musicisadirtyword.bandcamp.com. The Health Savings News podcast is produced by me, Evan O’Connor. All the sources we use in our research can be found in this episode’s podcast description on our website or your podcast of choice. Health Savings News is not intended to substitute professional medical, financial, or legal advice. Always seek the advice of a qualified healthcare professional or appropriate professional with any questions. Views expressed on Health Savings News are solely those of the individual expressing them. Any views expressed do not necessarily represent the views of Health Savings News, other contributors, the NeedyMeds organization or staff. Thanks again for listening. We’ll see you in two weeks with our next episode.