How to avoid surprise bills – and the pitfalls of the new law

Patients are no longer required to pay for out-of-network care given without their consent when receiving care at hospitals covered by their health insurance since a federal law took effect earlier this year.

But the law’s protections against the infuriating and costly scourge of surprise medical bills can be as good as the patient’s knowledge — and their ability to ensure those protections are enforced.

Here’s what you need to know.

Meet the law without surprises.

Studies have shown that approximately 1 in 5 emergency room visits result in a surprise bill.

Surprise bills often come from, among others, emergency doctors and anesthesiologists, specialists who are often outside the patient’s insurance network and not chosen by the patient.

Before the law came into effect, the problem was as follows: Say you needed surgery. You have chosen a network hospital, that is, a hospital that accepts your health plan and has negotiated prices with your insurer.

But one of the doctors who treated you didn’t take out your insurance. SURPRISE! You have a big bill, separate from hospital bills and other doctors’ bills. Your insurer didn’t cover much of it, if they didn’t outright deny the claim. You had to pay the balance.

The new law, known as law without surprisestates, in general terms, that patients seeking care at an in-network hospital cannot be charged more than the in-network negotiated rate for out-of-network services they receive there.

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

But the law creates wiggle room for providers who want to try to circumvent the protections.

Attention: the law leaves out a lot of medical care.

The changes come with many caveats.

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

Patients must hold their heads up high to avoid the remaining pitfalls, said Patricia Kelmar, director of healthcare campaigns for the nonprofit public interest research group, which lobbied for the law.

Suppose you go to your annual exam and your doctor wants to run some tests. Ideally, there’s a lab just down the hall.

But the lab may be off-grid, despite sharing office space with your networked doctor. Even with the new law in effect, this lab does not have to notify you that it is off the grid.

Beware of the “surprise billing protection form”.

Out-of-network providers can present patients with a form discussing their unexpected billing protections, titled “Surprise Billing Protection Form”.

The signer waives these protections and instead consents to treatment at out-of-network rates.

“The title of the form should be something like I give all my surprise billing protections when I sign this formbecause it really is,” Kelmar said.

Your consent must be given at least 72 hours before receiving care — or, if the service is scheduled for the same day, at least three hours in advance. If you’ve waited weeks to book a procedure with a specialist, 72 hours may not seem like enough time to cancel the procedure.

Among other things, the form must include a “good faith estimate” of what you will be charged. For non-emergency care, the form should include the names of network providers you might see instead.

He must also inform you of an unfortunate catch: the provider can refuse to treat you if you refuse to waive your protections.

It is illegal for some providers to give you this form. These include emergency physicians, anesthesiologists, radiologists, assistant surgeons, and hospitalists.

Keep your antennae on costs. Many patients report being simply handed an iPad to record their signature in emergency rooms and doctor’s offices. Insist on seeing the form behind the signature so you know exactly what you are signing.

If you notice a problem, don’t sign, Kelmar said. But if you find yourself in a difficult situation, for example because you receive this form and are in urgent need of care, there are ways to fight back:

  • Write on the form that you are “signing under duress” and note the problem (eg, “Emergency medical facilities are not permitted to submit this form”).
  • Take a picture of the form with your notes on it. Also consider filming a video of yourself with the form, describing how it violates federal law.
  • Report it! There is a federal hotline (1-800-985-3059) and a website for reporting all violations of the new law prohibiting surprise invoices. The hotline and website help patients determine what to do and collect complaints.

Speaking of that “good faith estimate”…

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

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

Theoretically, this gives patients a chance to cut costs by shopping around or choosing not to pay with insurance. It is of particular interest to patients with high-deductible insurance plans, but not exclusively: The so-called cash price of care can be cheaper than paying with insurance.

Also: It would be good to ask if this is an all-inclusive price, and not just a base price to which other ancillary services can be added.

It’s not enough to ask, “Do you take my insurance?”

It is always the patient’s responsibility to determine whether medical care is covered. Before you end up in a treatment room, ask if the provider accepts your insurance and be specific.

Kelmar said the question to ask is, “Are you in my insurance plan’s network?” Indicate the plan name or group number on your insurance card.

The reality is that your insurance company – Blue Cross Blue Shield, Cigna, etc. – has a bunch of different plans, each with its own network. A network can cover a certain provider; another may not.

Keep an eye on your mailbox.

To make sure no one is charging you more than you expect, be careful with your mail. Hospital visits, in particular, can generate a lot of paperwork. Everything billed should be itemized on a statement from your insurer called an explanation of benefits, or EOB.

Notice something? Make a few calls before you pay – to your insurer, to the provider and, of course, to the new federal helpline: 1-800-985-3059.

Dan Weissmann is the host of “One arm and one lega podcast about the cost of health care. This column is adapted from its newsletter First aid kit.

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