By Shelby Smoak, Ph.D.
This could happen to you: you’re on vacation and experience a terrible bleed in your foot. So tremendous is the pain that you grow concerned it may be a stress fracture. After a night of unrelenting pain, you call a nearby Urgent Care center and confirm they are in-network. No problem, you say. And you go. An X-ray is taken. The foot is diagnosed as not being broken. You go home.
Then the bills come. While all your services at the in-network clinic were covered as in-network costs, the X-ray was sent to a third party for review. And, well, they were out-of-network. Zing! Surprise! This results in a high-cost item not covered by insurance. This is an example of Surprise Billing and renders you helpless to negotiate the cost. There is nothing you could do about it… until now.
In January 2022, the No Surprises Act took effect. This bill is meant to end those nefarious charges that appear on the explanation of benefits (EOB) listed as “OON” or Out-of-Network and are the result of care received at in-network facilities. Let’s take a look at what the No Surprises Act is and isn’t.
What is a surprise bill?
The most succinct answer is that a surprise bill is an unexpected bill, but that could be any bill you hadn’t anticipated. Specific to healthcare and this act, a surprise bill refers to a balanced bill where a provider bills the patient for the difference between their charge and the amount paid by your health plan.
Why would someone receive a surprise bill?
A surprise bill is more often than not the result of an out-of-network charge. When a charge is in-network, the provider and the insurance plan have a previously agreed-upon arrangement for what the provider will charge and what the insurance will pay. With an out-of-network cost, no such agreement exists: the provider will charge what they feel is appropriate, the insurer will pay what they feel the service is worth. When these two figures do not align, usually with the provider asking for more than the insurer is willing to pay, the patient is billed by the provider for the balance difference, hence balanced billing.
In what scenarios might a surprise bill be received?
Numerous situations might lead to a surprise bill, but a majority of these can be related to emergency (ER) services. In these situations, providers often must act quickly. They may not be fully equipped for diagnosis and treatment within the facility and may use contracted help, as exampled above where the X-ray was read by a third-party source, even though the facility and X-ray technician were in-network at the facility. A blood draw and lab test may be taken where the phlebotomist is in-network, but the sample is farmed to a testing service that happens to be out-of-network.
Another common scenario may involve a procedure where a specialized provider, like an anesthesiologist, may be out-of-network, even though the procedure facility and the primary physician/surgeon are in-network.
How can you determine if your claim was an in- or out-of-network claim?
On most Explanation of Benefit (EOB) claim forms, these are noted or coded as OON (out-of-network), or the insurer’s EOB may include a note about the provider being out-of-network to indicate why the full provider cost is not being met. If you are unsure about the explanation on the EOB, you can also call the insurer for clarification.
What does the No Surprises Act cover?
According to the Centers for Medicare & Medicaid Services (CMS), the No Surprises Act provides consumers with “billing protections when getting emergency care, non-emergency care from out-of-network providers at in-network facilities.” It also provides out-of-network protections for air ambulance services.1
What situations do the No Surprises Act not cover?
The Act does not cover out-of-network billing from ground ambulance services. In many cases, a ground ambulance may be contracted with an in-network provider but be out-of-network with your insurance plan, and, unfortunately, the No Surprises Act does not offer patient protections in this situation.
The No Surprises Act also does not protect you if your provider (ER, hospital clinic or other facilities) is out-of-network. To be applicable, the out-of-network claim in question must have occurred within or at an in-network facility or provider.
What happens if my emergency care is at an out-of-network facility?
Unfortunately, the No Surprises Act does not specifically address this situation. However, emergency care is provided under the ACA and requires that providers must match in-network copayment and coinsurance rates when care is received at an out-of-network facility, so there would be some leverage for disputing an out-of-network charge in such an event.
Will the No Surprises Act automatically take effect when I receive an out-of-network bill?
No. The Act provides you with the protection to challenge the charge, but it does not require providers and insurance plans to flag out-of-network claims, nor are they required to determine if one of your out-of-network claims meets the criteria of a surprise bill. It is the patient’s responsibility to read the insurance plan’s EOB and determine if an out-of-network claim occurred at an in-network facility.
How do I dispute a medical claim that I think is a surprise bill?
If you believe you are the victim of a surprise bill, you can challenge the charge with the insurer and provider:
Obtain the itemized bill from the provider
Obtain an explanation of the charges from the medical provider
If you are going to appeal, let your provider know and ask them not to send the outstanding bill to collections
Call your insurer to discuss the charge
Be sure to document all of your communications with the insurer and provider during this process. Take detailed notes—include manner of communication (email, phone, etc.), date, time, person’s name, and department. Request contact confirmation numbers when available.
CMS has designated an arbitration process for the plan and provider to work out the charges without your involvement. The important point is that once you receive a confirmation of a surprise bill, you should not be paying an additional fee, or settling the “balanced bill” with the provider.
The No Surprises Act is new to 2022 and is likely to have some bumps, but it’s important to know the law and know your rights. If you have any questions, please reach out to your RCC at BioMatrix or our education team at education@biomatrixsprx.com. We hope this helps you stay protected in 2022 and forward.
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References
CMS. “Surprise Billing and Protecting Consumers.” 14 Jan. 2022. https://www.cms.gov/nosurprises/Ending-Surprise-Medical-Bills.
Controlling Costly Care: Lawmakers Weigh Surprise Billing, Transparency Legislation. https://cdn.theindianalawyer.com/wp-content/uploads/2020/02/Focus_SurpriseBills_IL021920_BradTurner.png.
Accessed 25 Jan. 2022.
