There was a story that came out early last week that got buried and lost amid the avalanche of negativity coming out of Washington, one that bodes well for American consumers and has been a long time coming.
Congress passed and President Trump signed a bipartisan law that will protect patients from unexpected bills from out-of-network medical providers, a practice that’s been termed “surprise medical billing” or “balance billing.”
This happens when you obtain care from a medical facility, usually a hospital, that participates in your health insurance network, then later get hit with large bills from out-of-network practitioners such as anesthesiologists, radiologists, or other specialists who practice there. These charges are usually not covered by your insurance plan at all or are covered at 50 percent or less, leaving you on the hook for potentially thousands of dollars. They also often don’t count toward your annual out-of-pocket maximum or your deductible.
Just such a thing happened to me in 2008, when I checked into a Chicago hospital for an outpatient procedure. I did my due diligence and made sure to confirm ahead of time that the hospital took my insurance, as did the surgeon. Never did it occur to me there might be someone working there who wasn’t in my network, and they certainly don’t warn you of that when you check in, at least not orally.
So I was dismayed a couple months later to receive a bill from an out-of-network anesthesiologist for charges that were rejected by my insurance company. How could this happen, when I’d made sure beforehand that the hospital was in my network?
What was I supposed to do? Inquire of each and every person who touched me that day whether or not they took my plan? Ask the anesthetist while I’m being wheeled into the operating room: Excuse me sir, do you take the United HealthCare student plan? You usually don’t even meet these folks until about a minute or two before they knock you out, and insurance is not exactly paramount in your mind then.
And you are still legally on the hook for it because of that fine print in the paperwork they make you initialize and sign when you check in.
It’s ridiculous. It’s my opinion that every independent practitioner who practices at a hospital or medical facility, if not employed directly by the facility, should be required to participate in the same insurance plans that the facility itself accepts. Otherwise the result is grossly unfair to unsuspecting patients. Especially in medical emergencies where you don’t even have a say in where you are taken or who touches you.
Pretty much everybody has these types of stories or knows someone who does.
It’s because of this fundamental unfairness that Congress finally addressed this problem in the form of the No Surprises Act, which will go into effect starting next year. It removes patients from the equation entirely by requiring out-of-network providers to negotiate directly with insurers for reimbursement, allowing arbitration when the parties cannot agree. Instead, the patient is only responsible for the same out-of-pocket they would have had to pay for the same service to an in-network provider. This is the way it should be.
There are a couple of catches. The law exempts ground ambulance services (air ambulances are covered). So a patient would still be responsible for those types of out-of-network bills. There’s also an exception when a facility notifies the patient at least 72 hours in advance of receiving services that a particular service provider is out of network, and the patient consents. But at least they have to proactively notify you and you have to knowingly agree, unlike before.
There appears to be some disagreement among health industry observers and experts over whether the new law will ultimately result in lower or higher healthcare costs and health insurance premiums. As we know, insurers facing new coverage requirements eventually pass it right back to us in the long run.
Nevertheless, a change we can all agree on is cause for quiet celebration in these divided times.