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Patient advocate weighs in on federal legislation aimed to address surprise medical bills

Hospital Hallway
Posted at 5:30 AM, Nov 12, 2021
and last updated 2021-11-12 10:26:30-05

Emergency room bills can be so expensive. Especially if you find out the provider you went to isn't covered by your insurance plan. They're often referred to as surprise bills -- those out-of-network charges you had no idea were coming. But starting next year, federal legislation will give patients new protection from high out-of-pocket costs.

The legislation is called the "No Surprises Act." Starting in January of 2022, it will impact anyone who has insurance through their job, through the marketplace, or through an individual health plan.

"We in Wisconsin do not have a surprise billing or balance billing legislation at all," said Christine Van Haren, an independent patient advocate with A Better Way Advocacy.
"So this will be a welcome change for us," she said.

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The Centers for Medicare and Medicaid Services (CMS) highlight the protections in the No Surprise Act here.

They include banning surprise billing for emergency room visits. So if the hospital ER you go to is out-of-network, meaning the hospital or doctor doesn't have a contract with your health insurance provider, you have to be covered as if they were part of your plan's network, also known as "in-network."

"That includes all of the providers that are there. If you have lab work done, if you have imaging done, it all has to be covered as if it were in-network," said Van Haren.

"It will save you money if you're vacationing and go to an emergency room. They can't bill you as if you were out-of-network," Van Haren added.

According to the CMS, the No Surprises Act also bans what's called balance billing and out-of-network cost-sharing "for emergency and certain non-emergency services. In these situations, the consumer's cost for the service cannot be higher than if these services were provided by an in-network provider, and any coinsurance or deductible must be based on in-network provider rates."

The legislation also bans out-of-network charges you received from an in-network facility. So for example, if you went to the emergency room and you were seen by an anesthesiologist who wasn't covered by your plan, you won't be charged the out-of-network cost.

Additionally, CMS says it bans "certain out-of-network charges and balance billing without advance notice." So, medical providers have to give patients a heads up and tell patients consent is needed to get out-of-network care before they can bill the person.

Van Haren stresses the legislation doesn't mean patients don't have to deal with their deductibles.

"You still are responsible for paying your deductible. So, if the $5,000 bill comes to your home and you haven't met your $6,000 deductible yet, you will be responsible for that $5,000."

She also says urgent care doesn't fall into the same category as emergency care.

"Urgent care visits would be considered out-of-network if you go to an urgent care or immediate care that is not in your network," she said.

While there are benefits of the legislation, Van Haren feels it includes a complicated independent review process if you end up needing to appeal your charges.

"Unfortunately it's not going to make it any easier. It's going to make it more difficult for patients," she said.

"Ideally you don't want to get to that point in the first place. You want to prevent these surprise bills. But when there is a surprise bill, it has very specific time limits for the provider and the insurance company to work things out," she explained.

Van Haren says even with this legislation taking effect, patients should continue to do their research and learn about their health insurance plan.

"There are insurance companies who are limiting what they will pay for emergency room visits. So for instance, if you think you have a sinus infection, that will not pay for an emergency room visit."

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