Surprise Medical Billing

Everything you need to know about Surprise Medical Billing in 2022.

Surprise medical billing is a large issue being discussed across the country. According to the Kaiser Family Foundation, it’s a common scenario that happens in about 1 in 5 emergency room visits and in about 1 in 6 inpatient admissions.

If you have insurance, you would probably call the hospital or your insurer first to make sure the hospital was “in network” with your insurance. You might also need to double-check that the surgeon who will be operating on you is in-network, too.

But even if you do your homework before your elective surgery, you can still be at risk of receiving large bills you never would have expected, from providers you’ve never met or even knew about.

According to a recent JAMA study, surprise bills happen about a fifth of the time that a patient has an elective surgery at an in-network hospital with an in-network surgeon. 

The average unexpected charge of about $2,000 more than what insurance would typically pay can hurt anyone, especially vulnerable populations.

The good news is that starting January 1, 2022, you won't have to fear as many surprise medical bills as the No Surprises Act goes into effect. The new legislation is meant to put an end to this practice.

What is Surprise Medical Billing?

Surprise medical billing occurs when a patient receives a larger-than-expected medical bill due to their care provider being out-of-network.

In most situations, the patient is not aware that they received out-of-network care so it comes as surprising. It typically occurs in the following scenarios:

• Emergency care situations and nonsurgical hospital stays, when patients may not be able to choose health care providers covered by their insurance.
• An out-of-network provider renders service to a patient at an in-network hospital.
• In situations with surgical complications as the procedure grows more complex, more people get involved in treating it and one or a few might be out of network.

Most of the surprise bills come from either anesthesiologists or surgical assistants — who are typically not chosen by patients. They could also come from out-of-network pathologists, who analyze tissue and blood samples, or radiologists, who examine X-rays and MRIs.

How Do Patients View Surprise Medical Bills?

Surprise medical billing is leaving patients all over the country with large unexpected medical expenses, sometimes totaling hundreds of thousands of dollars.

According to a new study by Yale researchers, addressing the issue could reduce health spending by 3.4% which translates to $40 billion annually.

Many patients view surprise medical billing as an unfair and unjust practice in the medical community. Surprise medical billing often leads to financial hardship for patients who are not prepared to pay the large sum.

Most often, this unexpected medical cost falls in their lap after unplanned emergency care. 

When a patient enters the emergency department, they are not considering that a doctor, whom they do not know, would be out-of-network in a hospital they know to be in-network.

No Surprises Act (NSA) To End Surprise Medical Bills in 2022 

On Jan. 1, 2022, the “No Surprises Act” (NSA) consumer protection law went into effect. 

The Act protects patients from surprise medical bills when they receive unanticipated out-of-network care in emergency and nonemergency settings.

Patients are only required to pay to the in-network cost-sharing, including any applicable co-payment, coinsurance and deductible for out-of-network emergency medical care at in-network facilities. 

You shouldn’t receive a surprise medical bill from an out-of-network provider in the following scenarios:

• When you receive emergency care in an emergency room
• When you receive any care at an in-network health-care facility
• When you are transported by an air ambulance (airplane or helicopter)

Emergency care providers also can’t charge you out-of-network rates for services rendered once you’re in stable condition, unless you provide consent and you’re able to freely travel on your own to an available in-network provider.

Out-of-network service providers are also required to give patients 72-hour notice of their estimated charges. Patients would have to agree to receive out-of-network care for the hospital or doctor to then bill them.

The legislation also establishes an arbitration process for resolving out-of-network provider claims to be paid by health plans. There is a 30-day open negotiation period for providers and payers to settle out-of-network claims. If a solution cannot be reached, an independent arbiter will be brought in to determine a fair reimbursement.

Most importantly, patients will be removed from payment disputes that must be settled between providers and insurers.

In implementing the NSA, the Biden-Harris Administration also issued a series of regulations that, starting January 1, 2022, will finally provide patients with individual or employer health coverage relief from surprise medical billing and reduce health care costs.

The Congressional Budget Office (CBO) predicts that the No Surprises Act will reduce health insurance premiums for consumers by 0.5% to 1% on average.

By significantly reducing out-of-network surprise bills, the NSA will reduce out-of-pocket costs, reduce anxiety, financial stress, and medical debt. 

Hopefully this legislation will finally put an end to surprise medical billing. Patients would no longer have to fight these surprise medical bills at the same time they are facing a medical crisis.