Updated: Oct 7, 2021
This column first appeared in the San Antonio Express News and other Hearst Newspapers on December 30, 2020.
Dear Mr. Premack: Is this legal? 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, that 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. – 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 for a few years. It took a long time to find a solution because of the lobbying interests involved. 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 and recently signed by the President. The new law on surprise medical bills will not take effect for another year, until January 2022. Until then you are still exposed to the problem. After then, the solution works as follows:
First, the burden will be removed from you as the patient. Your financial exposure will be 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.
Second, 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. If the provider is not satisfied, they can negotiate for a different payment with your insurance company. If they don’t agree, the law imposes using an independent arbitrator to set a fair payment based on a variety of factors.
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.
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.