Benefit Bulletin: February 2022

New Federal Protections Against Surprise Medical Bills Take Effect, But Rely on Patients Knowing Their Rights

By Rick Delaney, Chairman of the Board

It’s a new year, and that means your doctor’s office, hospital, and outpatient services departments have a fresh batch of forms for you to sign.  It’s more important than ever to read those forms before signing!  You don’t want to inadvertently agree to significantly higher costs because you signed away your rights to new federal protections against surprise medical bills.  Email we receive indicate that too many of you have received surprise bills in the past and, as a result, some of you are carrying debt that you haven’t been able to pay off.

While the new law against surprise medical bills has taken effect, it’s effectiveness in reducing costs will rely on the patient’s vigilance and understanding of the new rights, according to the details of new brief from the Kaiser Family Foundation.  Surprise medical bills refer to bills from out-of-network doctors, hospitals, or other providers that you did not choose (such as a radiologist that you never saw when getting a scan.)  Studies have found that these surprise bills happen a lot — in almost one-out-of-every 5 visits to the emergency room.  They can also arise during in-network hospitalizations for non-emergency care when using one or more out-of-network providers.

While surprise medical bills potentially could happen to anyone, they are particularly a problem for those of you enrolled in Medicare Advantage plans.  This is especially so for those who are enrolled in a Medicare Health Maintenance Organization (HMO) which contracts with a specific network of healthcare providers.  The new law:

  • requires private health plans to cover out-of-network claims and apply what you would otherwise owe for in-network cost-sharing (deductibles, co-pays or co-insurance), and,
  • prohibits doctors, hospitals, and other covered providers from billing patients more than in-network cost sharing amount.

But there are exceptions if patients give written consent to out-of-network services, by signing forms waiving their rights to the new protections.  Ironically the form is entitled “Surprise Billing Protection Form.”  Beware!  While providers are not allowed to ask patients to waive their rights for emergency services or for certain other non-emergency services, providers can refuse care if consent is denied.

The new protections apply to emergency services provided in hospital, and freestanding emergency departments.  It applies to air ambulance transportation but not ground ambulances.  It applies to services provided in a hospital following an emergency visit, known as “post stabilization care.”  Finally, it also covers non-emergency services provided by out-of-network providers who provide services at in-network hospitals and other facilities.  This could include, for example, an anesthesiologist, or another provider who might not be employed directly by your network hospital, but instead bills independently, and may not be part of your health plan.

Due to the way the regulations are written, TSCL believes that oversight and enforcement will rely on complaints from patients.  But in order to complain, patients will need to understand that they should not be overbilled for emergency services or by out-of-network providers who provide services for in-network hospitals.  Based on our experience, most of the public doesn’t know all that much about the ins and outs of their healthcare coverage, how billing should work, or their rights to federal protections.  This is especially true for Medicare recipients. How Medicare beneficiaries and their families will be educated about the new rights is yet to be determined.

The nonpartisan Kaiser Family foundation has a helpful video that explains the new ban on surprise medical bills.

Source:  “No Surprises Act Implementation: What to Expect in 2022,” Karen Pollitz, Kaiser Family Foundation, December 10, 2021.