When No Surprises are a Good Surprise

One of the best “surprises” of 2022, which affects anyone paying bills for healthcare, is the “No Surprises” Act.(1) It went into effect at the start of the year. What the act is intended to do is indicated in its name. Officially, it is part of the Consolidated Appropriations Act of 2021, its purpose is to eliminate a large majority of “surprise” medical bills. These typically occur in emergency situations when the ability to guide the patient towards in-network is not feasible due to haste or location (with one major exception, which we will explain later).

The Surprise Prior to January 1, 2022, if someone was injured, requiring urgent or emergency care, circumstances would rarely allow the person responsible for payment to determine what is in or out of network. That is where the surprise came into play. Accidents can be upsetting, if not outright traumatic, but then to be followed by a large medical bill because a provider was out of network added to the distress. Once the bill went into effect, that type of billing is now illegal.

The Impact According to various studies, out-of-network care represents approximately twenty percent of all emergency care.(2) Additionally, patients “surprise billed” with out-of-network status from an Emergency Department (ED) were paying ten times more than others than other ED patients.(3,4)

Of course, the issue, as with almost everything associated with US healthcare, can be even more complicated. If one had the ability, time, and presence of mind to research which facility is in-network, there are instances of the attending ER doctor not being so, and so still accounting for a surprise.(5)

In fact, one in six in-network patients receives surprise billings as well.(6) This is can be due to a patient receiving care from an in-network provider billing for an elective procedure deemed out of network, or most commonly, additional staff such as anesthesiologists or radiologists (6)

The Solution

The No Surprises Act (NSA) has a variety of provisions to address all these issues.(7) The protections include:

1. Ban surprise bills for emergency services, even if you get them out-of-network and without approval beforehand (prior authorization).

2. Ban out-of-network cost-sharing (like out-of-network coinsurance or copayments) for all emergency and some non-emergency services. You can’t be charged more than in-network cost-sharing for these services.

3. Ban out-of-network charges and balance bills for supplemental care (like anesthesiology or radiology) by out-of-network providers who work at an in-network facility.

4. Require that health care providers and facilities give you an easy-to-understand notice explaining that getting care out-of-network could be more expensive and options to avoid balance bills. You’re not required to sign this notice or get care out-of-network.

Important Exceptions Lastly, a service generally exempted is “road” ambulance service. As a New York Times article on this issue noted, “Ambulances have the highest out-of-network billing rate of any medical specialty, meaning most rides can result in a surprise bill. (8)” (Even if a hospital is in their network, that hospital’s EMS is often a separate, privately held company with its own network contract negotiations and may be out of network.) Therefore, as Karan Chhabra, a surgical resident at Brigham and Women’s Hospital notes in the article, “From a policy standpoint, the omission of ground ambulances is huge.” Additionally, ambulances also are some of the most likely to incur out-of-network charges, so their omission isn’t negligible.(2,9) That said, air ambulances are included in the ban.

Significant Consumer Protection For more information related to network billing, or to review your current plan, contact a Commonwealth Insurance Partners Benefits Advisor today.

References

1. https://www.cms.gov/nosurprises/Ending-Surprise-Medical-Bills

2. https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2016.0970

3. http://ncoil.org/wp-content/uploads/2021/04/Garmon_NCOIL_Presentation_4_16_2021.pdf

4. https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2020.01471

5. https://www.nytimes.com/2014/09/29/us/costs-can-go-up-fast-when-er-is-in-network-but-the-doctors-are-not.html

6. https://www.healthsystemtracker.org/brief/an-examination-of-surprise-medical-bills-and-proposals-to-protect-consumers-from-them-3/

7. https://www.cms.gov/nosurprises/consumers/new-protections-for-you

8. https://www.nytimes.com/2020/12/22/upshot/ground-ambulances-left-off-surprise-medical-bill-law.html

9. https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2019.01484

10. https://www.acr.org/Advocacy-and-Economics/Advocacy-News/Advocacy-News-Issues/Dec-25-2021-Advocacy-in-Action-Special-Report/ACR-Files-No-Surprises-Act-Lawsuit-to-Protect-Patient-Care

Other Resources

1. https://www.nytimes.com/2021/12/30/upshot/medical-bill-ban-biden.html

2. https://www.nytimes.com/2016/11/17/upshot/first-comes-the-emergency-then-comes-the-surprise-out-of-network-bill.html

3. https://www.nytimes.com/2020/12/22/upshot/ground-ambulances-left-off-surprise-medical-bill-law.html

4. https://www.nytimes.com/2020/12/20/upshot/surprise-medical-bills-congress-ban.html

5. https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2019.00507

6. https://www.cms.gov/nosurprises/policies-and-resources/overview-of-rules-fact-sheets

7. https://www.kff.org/health-reform/issue-brief/no-surprises-act-implementation-what-to-expect-in-2022/

8. https://www.healthsystemtracker.org/brief/an-examination-of-surprise-medical-bills-and-proposals-to-protect-consumers-from-them-3/

9. https://www.kff.org/private-insurance/fact-sheet/surprise-medical-bills-new-protections-for-consumers-take-effect-in-2022/

10. https://www.natlawreview.com/article/telemedicine-providers-take-note-no-surprises-act-effective-january-1-2022