Oh Hey, Goodbye, Surprise Medical Billing, And F*ck Off!

How did Dems pass something this good?

Yr Wonkette got an email from our health insurance company, and for once, we actually read it, because it explains the new "No Surprises Act" (NSA) that went into effect on January 1. It's such an astonishingly good set of regulations — for folks who have health insurance, at least — that the real surprise here is that it passed at all.

Democrats included No Surprises in the big omnibus government funding bill passed in December 2020. Somehow, it wasn't deep-sixed by Republicans in the Senate, and Donald Trump was so consumed with trying to steal the 2020 election that, despite threatening a veto, he went ahead and signed the bill anyway, albeit with a batshit crazy signing statement that everyone promptly ignored.

Read More: Joe Biden Drives Stake Through Heart Of Surprise Medical Billing 

Last year, the Biden administration went ahead with the normal process of rule-making to implement the law, and now folks with health insurance are protected from getting hit with a massive medical bill if an ambulance takes us to an out-of-network ER (except, weirdly, for the ambulance), or if we get surgery at an in-network hospital, but an out-of-network anesthesiologist assists. This is a heckin' big deal: The Kaiser Family Foundation (KFF) points out that the federal government "estimates the NSA will apply to about 10 million out-of-network surprise medical bills a year."

It's quite a victory for healthcare consumers, even as for-profit healthcare remains a deeply flawed way to run a healthcare system. 

The No Surprises Act ought to put an end to outrageous stories like that of the woman who had a really bad cold and wanted to make sure it wasn't strep throat, so she went to see her in-network primary care doctor — and was later billed over $25,000 because her blood test went to an out-of-network lab. Normally, when you have insurance, when you see healthcare providers that have a contract with the insurance company, all you have to pay is your copayment (and/or your deductible). But if you see a provider who's out of network, your insurer may pay only a portion of the bill, and you could be billed for the full costs. Sometimes people choose to do that, like if they definitely want to see a particular provider who isn't in network. That practice is called "balance billing" — you're on the hook for the balance of the charges over anything your insurance covers.

Read More: The $25,865 Head Cold. It's A Christmas Medical Miracle! 

"Surprise Billing" involves a balance bill you didn't expect, which could happen in an emergency, if an ambulance takes you to the nearest ER at a hospital that's out of network. Or it could happen when you schedule an appointment with an in-network facility and provider, but some part of your services involved another provider who's out of network. As KFF 'splains, 

Often, the doctors who work in hospitals don’t work for the hospital; instead they bill independently and do not necessarily participate in the same health plan networks. The federal government estimates that 16% of 11.1 million (or about 1.8 million) in-network non-emergency facility stays for privately insured patients each year involve at least one out-of-network claim.

To add insult to high-cost injury, those charges didn't even apply to your annual deductible, because hey, they were out of network.

As of January 1, that's pretty much over for situations where you receive out-of-network care that you didn't intend to. Here's how that works, as explainered by the federal Centers for Medicare & Medicaid Services (CMS), the part of HHS that administers the policy. The new rules will:

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

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

• Ban out-of-network charges and balance bills for certain additional services (like anesthesiology or radiology) furnished by out-of-network providers as part of a patient’s visit to an in-network facility.

• Require that health care providers and facilities give you an easy-to-understand notice explaining the applicable billing protections, who to contact if you have concerns that a provider or facility has violated the protections, and that patient consent is required to waive billing protections (i.e., you must receive notice of and consent to being balance billed by an out-of-network provider).

Emergency Services

If you're in an accident and are taken to an out-of-network emergency room with out-of-network doctors, the most the hospital and providers can charge you is your insurance plan's cost-sharing amount (copay and deductible) for in-network services. Our insurer's email adds that the rules also apply to "services you may get after you’re in stable condition," unless you agree in writing to waive your protections against balance billing — for instance, if you want a particular out-of-network provider and are willing to pay for those services. KFF explains that such "post-stabilization care" counts as emergency care under the rules

until a physician determines the patient can travel safely to another in-network facility using non-medical transport, that such a facility is available and will accept the transfer, and that the transfer will not cause the patient other unreasonable burdens.

The law also requires patients be notified in writing and give written consent to such transfers, so that should prevent hospitals from just dumping out-of-network patients before it's safe for them to be transferred.

One caveat:  KFF notes that the new law "applies to air ambulance transportation (emergency and non-emergency), but not ground ambulance." More on that here:  

the law instead requires a federal advisory committee to study the issue and recommend options to protect patients from surprise bills.

This analysis finds that half of emergency ground ambulance rides result in an out-of-network charge for people with private health insurance, potentially leaving patients at risk of getting a surprise bill.

Yr Wonkette is not going down any rabbit holes on why ground ambulances weren't included in the new regulations; our guess is that it was prevented by some regulatory magic line between hospital services and ambulance services.

Non-Emergency Services At In-Network Facilities

If you get non-emergency services at an in-network hospital or other facility, and an out-of-network provider is involved, (say, an anesthesiologist or a radiologist), you can't be charged more than your insurance plan's in-network cost-sharing amount. Our insurance company's email explains that applies to "emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeons, hospitalists, or intensivist services." They just plain aren't allowed to balance bill you without your written consent, and they also are prohibited from asking you to give up your protections from balance billing.

What If You Don't Have Insurance?

The No Surprises Act only goes so far — the feds can regulate insurance, but without congressional action, folks with no insurance at all are mostly out of luck. However, as CMS explains , NSA does at least now require that providers and facilities give a "good faith estimate of how much your care will cost before you receive it," and patients will have the ability to dispute any medical bills that are more than $400 above that estimate.

Also, folks who get their health coverage from the government — Medicare, Medicaid, the TRICARE insurance for military families, as well as those who get healthcare through the Indian Health Services or the Veterans Health Administration — are already protected from surprise balance billing, so that's a relief too.

Finally, since some states have their own laws against surprise medical billing, NSA is intended only as a floor for protections: If a state has stronger protections than are in NSA, those won't be reduced by the new federal law.

If you have insurance through your job, or a private plan through Obamacare, you've probably gotten an email like the one we received from our health insurer; for more on how this all works, see the overviews at the federal CMS website and at Kaiser Family Foundation . (The KFF link has a good discussion of how this will all be enforced, including what you can do to dispute surprise medical bills if you still get one, which you shouldn't.)

Now let's get working on some nice Euro-style universal healthcare, with price controls and all that, to make sure everyone has healthcare.

[ CMS / Kaiser Family Foundation ]

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