For decades, hospitals and medical providers have hidden what their costs will be from patients. AND they’ve hidden whether or not everyone in the hospital is an “in network provider” for the purposes of what they can charge. Typically anesthesiologists were out-of-network. They would band together in a “group” and provide services to hospitals — for which they can charge far more than the in-network amount. And when insurance covered only the in-network amount, patients got a bill — SURPRISE! — for thousands, sometimes tens of thousands, of dollars.
We posted about this in October 2018 — See “How your state lets insurance companies screw you.” At the time , Rep. Lloyd Doggett (D-Texas) and Sen. Bill Cassidy (R-La) had both introduced bills to protect us — but neither bill was passed.
Fortunately, the “No Surprises Act” was passed the end of 2020. It goes into effect for health plan years beginning on or after 1/1/2022. It applies to “nearly all” health insurance plans.
Some of the highlights include protecting against:
- Emergency services that hospitals previously excluded from in-network billing
- Insurers who retroactively declare emergency services weren’t needed due to the final diagnosis. (A “reasonable” person thinks they might be having a heart attack and rushes to the hospital. The doc finds they weren’t having one — so the insurance company would say the ambulance and special emergency services weren’t needed so they won’t pay.)
- Air ambulance services not included in “in-network.” If your insurance plan covers them, they cannot be excluded.
The No Surprises Act also applies to self-funded employer insurance plans formed under the Employee Retirement Income Security Act (ERISA plans) and air ambulance services. States have not been able to prevent surprise billing from these two key areas because they are governed by federal law. Now they’ll be covered for us all.
Exceptions can still be made from being covered by “in-network” rates. But they can no longer be a surprise. If you pre-book an operation, details must be provided to you at least 3 days prior to the operation of any out-of-network costs you are likely to occur. AND they must give a good faith estimate of those specific costs. And each out-of-network supplier must get separate consent from you — they can’t rely on your consent to another provider. Such notices must also appear on their websites and be easily found through search, as well as posted prominently where appointments are schedule.
Frankly, a lot of this is still very unclear. Take this paragraph from the National Law Review:
“In the context of non-emergency services, the exception does not apply to ancillary services, which include items and services related to emergency medicine, anesthesiology, pathology, radiology, and neonatology, whether provided by a physician or non-physician practitioner; items and services provided by assistant surgeons, hospitalists, and intensivists; diagnostic services, including radiology and laboratory services; and items and services provided by an out-of-network provider in circumstances where there is no in-network provider who can furnish the item or service at the relevant facility.”
This appears to say that anesthesiology, et al., for non-emergency services, can’t claim an exception. So they are covered by in-network pricing. But… you should get it in writing. I know I will(!)
And… consider postponing any elective surgery until 2022.