Updated: Jan 18
About a year ago, I posted a column about a new law that bans surprise medical bills. That new law took effect this week (January 2022) so I am reposting to bring the new law back to your attention.
Dear Mr. Premack: Two weeks after visiting an emergency room, I got a bill for $1800 from an out-of-state medical corporation. It was hard to tell what the bill covered, and in the fine print it gave the name of a doctor I never remember visiting. After checking, I found out this was the doctor I saw for ten minutes in the emergency room who gave me a prescription. I found out the doctor was not a participant in my insurance plan (even though the emergency room was a participant) and that I must pay this surprise bill out of pocket. Is it legal to bypass my insurance in this manner? – I.C.
It sounds like you had the presence of mind to contact your health insurance carrier before going to the emergency room, so you knew the emergency room was covered by your policy. Once there, you talked to a doctor and were sent home with medication and with the knowledge that the visit was covered by your health insurance. Then you received an additional surprise medical bill.
Enough people shared that experience that Congress actually noticed. Several Congressional Committees discussed solutions but due to lobbying interests they took a long time to find a solution. Many medical providers have been purchased by private equity firms due to the extreme profits produced by the medical-insurance complex. They did not want a law that would cut into their gains.
The compromise solution was packaged into the Covid-19 relief legislation passed by Congress in 2020 and takes effect on January 1, 2022. Until now, surprise medical bills were still legal. But as of the effective date, the new legal process works as follows:
1. The burden is removed from you as the patient. Your financial exposure is limited to what you would have to otherwise pay for deductibles and out-of-pocket limits under your health insurance in-network provisions. That can still be substantial but is not a surprise. Also, remember that if the emergency room or hospital is out-of-network for your insurance policy you may not be protected at all.
2. A health care provider who works in an in-network facility but is not a participant in your health plan will be paid the rate due under your health plan (you pay if your deductible is not met; insurance pays if your deductible has been met). If the provider is not satisfied, they can negotiate for a different payment with your insurance company. If they don’t agree, the law requires them to use an independent arbitrator to set a fair payment based on a variety of factors.
3. The new law insulates you from involvement in the negotiation or the arbitration. Just the care provider and the insurance company will argue over the fee. You will not receive a bill for the amount decided upon; it will be paid under your health insurance policy as though the provider had been in-network all along (unless your deductible has not yet been met for the year, in which case you pay).
The new law includes banning surprise bills for air-ambulances, but it does not ban surprise bills for regular ground-based ambulance charges. Ambulance bills can cost hundreds of dollars so be aware that you can still be billed outside your insurance policy for ground ambulance transportation.
Paul Premack is a Certified Elder Law Attorney, handling Wills and Trusts, Probate, and Elder Law issues. He is licensed to practice law in Texas and Washington. View past legal columns or submit free questions on those legal issues via www.Premack.com.