By Trish Pearson
Insuring Your Future
Trish Pearson
The No Surprises Act, passed last year, has finally gone into effect. Put simply, the NSA establishes new federal protections against surprise medical bills. These bills arise when insured consumers inadvertently receive care from out-of-network hospitals, doctors or other providers they did not choose.
A classic example of such a case is a colonoscopy where the gastroenterologist is in-network, but the anesthesiologist is not. The patient does not expect a copay because it is a “screening” procedure, but receives a bill because the anesthesiologist is “out of network.”
Thanks to the NSA, this is not the patient’s problem. Do not pay an unexpected bill from a provider who was part of the operation package. If such a situation arises, call both the provider and the insurance company, explain that you were not consulted nor did you choose the anesthesiologist. It is between the providers and the insurance company to figure out.
The NSA will protect consumers from surprise medical bills by requiring private health plans to cover these out-of-network claims and apply in-network cost sharing. The law applies to both job-based and non-group plans, as well as Medicare plans. It also prohibits doctors, hospitals and other covered providers from billing patients more than the in-network cost sharing amount for surprise medical bills.
Another example of surprise billing applies to treatment for emergency services. Surprise billing protections apply to most emergency services, including those provided in hospital emergency rooms, freestanding emergency departments and urgent care centers that are licensed to provide emergency care. Emergency care includes screening and stabilizing treatment sought by patients who believe they are experiencing a medical emergency or active labor.
The act also covers post-emergency stabilization services defined as services provided in a hospital following an emergency visit. Post-stabilization care is considered emergency care until a physician determines the patient can travel safely to another in-network facility using non-medical transport, that such a facility is available and will accept the transfer and that the transfer will not cause the patient other unreasonable burdens.
This is especially important if the patient’s “network” is in another state that would require extended travel. The NSA also requires that the patient get written notice and give written consent to be transferred.
Finally, the NSA covers non-emergency services provided by out-of-network providers at in-network hospitals and other facilities. Often, the doctors who work in a hospital don’t work for the hospital; instead, they bill independently and do not necessarily participate in the same health plan networks. The business of medicine has created a complicated web of relationships that can impact the billing process. While this may not be prevalent in Connecticut it is very common in other states, such as Florida.
The regulation broadly defines covered non-emergency services to include treatment, equipment and devices, telemedicine services, imaging and lab services and preoperative and postoperative services, regardless of whether those services are provided within the facility itself.
Hoping for a better 2022. Think positive and test negative.
Trish Pearson is a licensed independent insurance agent and certified long term care specialist. Contact her at 203-640-5969 or trishpearson281@gmail.com.