In January of 2022 the No Surprises Act was passed into law. Oftentimes, when a patient receives medical care outside of the health insurance company’s provider network, the patient is faced with steep out of pocket costs.
The legislation recognizes the fact that there is a difference between choosing to see an out of network provider and being assigned an out of network provider during an emergency as one example. The new law applies to individual and group policies, and even some protection for the uninsured. Medicare policyholders are not covered by the law, as most Medicare providers are already limited in how much they may balance bill.
The No Surprises Act limits hospitals and doctors from charging over and above the patients’ health insurance limits for emergency services. If a patient is taken to an out of network hospital during an emergency, the hospital must accept the patient’s insurance reimbursement rates as payment in full.
One common scenario is the patient that receives care from a member of a medical group. Anesthesiologists and emergency room physicians commonly form medical groups. Members of these groups may work at an in-network hospital but may not be contracted with the patients’ health insurance company. These medical groups are formed so that they may charge more for their services than most PPO plans reimburse. The patient would often receive a shockingly high surprise bill from the medical group, not realizing that the doctor in the emergency room was not an in-network hospital physician. With the new law this situation should no longer occur. If the medical groups had simply charged reasonable rates to begin with there would be no reason for the new law.
For the many millions of uninsured the Act mandates that these patients receive good faith estimates and billing protections. The patient must also receive contact information in case of a dispute.
The No Surprises Act includes protections relating to air ambulance bills, but not ground ambulance bills… at least not yet. Ground ambulance services is a complicated mess, with services provided by private companies, states, police, counties, etc. With the passage of the new law hopefully ground ambulance service providers will get the message to clean up their act before the government comes knocking at their door.