No Surprises Website and Help Desk

The Centers for Medicare and Medicaid Services (CMS) has established resources for patients to seek review of their medical bills through this website: cms.gov/medical-bill-rights/help/submit-a-complaint or by calling the No Surprises Help Desk at 1-800-985-3059 which is available 24/7 and through holidays. This no-wrong-door complaints system is available for consumers who are concerned their plan may have incorrectly denied or covered a surprise medical bill. (More information)

Surprise Billing Protections

As of Jan. 1, 2022, the “No Surprises Act” consumer protection law goes into effect. This legislation will ban most forms of surprise billing, or balance billing, in which a person unknowingly gets medical care by a provider outside their private insurer’s network, even when visiting an in-network facility. 

It’s a common scenario that happens in about 1 in 5 emergency room visits, according to the Kaiser Family Foundation. Even if you’re careful to choose an in-network physician or facility, part of your visit might require ancillary service providers not covered by your insurance, such as anesthesiologists, radiologists and intensivists. 

These ancillary services are often in the same building as an in-network provider, which only adds to the confusion of what’s actually covered through insurance, says Patricia Kelmar, a director of health care campaigns at U.S. PIRG. “It takes advantage of people at their most vulnerable moment,” she says, arguing that patients are not in a good position to police their insurance coverage, particularly when receiving emergency care.
“It’s not like you’re given a bunch of offers of who you can choose as a provider,” Kelmar adds. “The last thing you’re doing at that point is checking network status and asking for cost estimates.”

How the surprise medical bill protections will work

The new rules apply to private insurers, including those provided through the Affordable Care Act’s marketplace (surprise billing is already banned under Medicare and Medicaid).

As of Jan. 1, patients shouldn’t receive a surprise medical bill from an out-of-network provider in the following scenarios:

• When you receive emergency care in an emergency room
• When you receive any care at an in-network health-care facility
• When you are transported by an air ambulance (airplane or helicopter)

As well, emergency care providers can’t charge you out-of-network rates for services rendered once you’re in stable condition, unless you provide consent and you’re able to freely travel on your own to an available in-network provider.

In these scenarios, the consumer will no longer be the middleman between their provider and insurer, and will only pay for in-network costs. Any outstanding balance will have to be settled between insurers and the out-of-network medical providers. The law gives insurers and these providers 30 days to sort out discrepancies, and there’s a new arbitration process for them to settle their disputes.

Limitations to consider

Location matters. These new federal protections only apply to emergency rooms or departments, and urgent-care centers that provide emergency services. They also apply for hospitals, hospital outpatient departments and ambulatory surgery centers that are in-network.

However, these protections don’t apply to non-emergency services provided in other facilities like addiction treatment facilities, birthing centers, clinics, hospice, nursing homes, or urgent-care centers that aren’t licensed to provide emergency services. You’ll always want to check that these facilities and the services they provide are in-network, particularly for urgent-care centers.

The No Surprises Act also won’t cover ground ambulance transportation, even though you have almost no control over who provides the service. That means you still might receive an out-of-network balance bill for an ambulance. Some states do offer surprise bill protections specific to ground ambulances (but at this writing, NOT Massachusetts), otherwise your best bet is to call the ambulance provider and try to negotiate your bill, Kelmar says.

How to Protect Yourself from a Surprise Bill

When dealing with a health-care provider, it can sometimes be difficult to get a straight answer on exactly what’s covered by your insurer. Kelmar suggests asking, “Are you part of my plan’s network?” rather than, “Do you take my insurance?” as that will tell you more about what to expect for actual costs. 

Out-of-network doctors may ask you to sign the Surprise Billing Protection Form. Kelmar recommends that you don’t sign it until you’ve read it fully, you have a full estimate of charges and are willing to pay that amount. 

Emergency physicians or facilities, assistant surgeons, anesthesiologists, radiologists, hospitalists and intensivists are not allowed to ask you to sign this form. If you do end up signing this form, and it’s $400 higher than the estimate, you can dispute the bill by filing a complaint online here or by calling 1-800-985-3059.

If you receive a surprise medical bill after Jan. 1, 2022, contact both the provider and your insurer immediately. If they still insist on payment, you can file a complaint within 120 days online here, or by calling 1-800-985-3059.

What To Do If You Get a Surprise Bill Anyway

If you suspect you’ve received a now-banned bill, call your insurer first, experts say.

“If they can’t validate a bill and tell you that you shouldn’t have received it, call the provider next to ask what happened,” Donovan said. “If they insist that they can bill you, the best move may be to try to do a three-way call with yourself, your provider and your insurer.”

If both your insurer and your provider won’t amend the bill, you should submit an official complaint. The federal government has a new process for you to report suspected surprise medical bills. You can do so online or by phone at at 1-800-985-3059.

In the meantime, your provider could submit your bill to collections. “Remain calm,” Donovan said. “You still have protections.”

If you receive a call from a collections agency, inform them that you’re disputing the medical bill, Donovan said. As a result, they shouldn’t contact you for at least 30 days, while they’re confirming your claim.

“Do not pay anything towards the bill,” she warned. “That will count as you accepting responsibility for it.”

Fortunately, a medical bill generally shouldn’t show up on your credit report for at least 180 days. Hopefully by then the bill is fixed.

MGB Statement (Excerpted)

On January 1, 2022, the federal and Massachusetts’ “No Surprises Acts” take effect. These acts require that healthcare facilities – both hospitals and practices – notify patients at the time of booking an appointment if their insurance plan is considered non-contracted and/or out of network. Mass General Brigham is responsible to follow up with a cost estimate of what their balance will be, and the patient needs to sign a consent form if they choose to proceed with the appointment. As part of this rule, we are also required to publish a notice of the patient’s rights on all entity websites and in office locations.

In addition, good faith estimates are required for all uninsured/self-pay scheduled services and when requested by an uninsured/self-pay patient (e.g., shopping for services).

Questions can be directed to Lisa Finston, Mass General Brigham’s director of payor operations and revenue reimbursement.

Sources and for More Information

• These medical bills are now banned. What to do if you get one anyway (cnbc.com)
• https://www.cnbc.com/2021/12/29/a-federal-ban-on-surprise-medical-bills-takes-effect-jan-1.html
• Things you need to know today morning edition: Spreading holiday cheer, No Surprises Acts take effect Jan. 1, Broadcast MGB, December 29, 2021

(1/22)

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Previous Coverage:

Surprise Medical Billing: Interim Final Rule

On July 1, the Biden-Harris Administration, through the U.S. Departments of Health and Human Services (HHS), Labor, and Treasury, and the Office of Personnel Management, issued "Requirements Related to Surprise Billing; Part I," an interim final rule that will protect patients from surprise billing. This interim final rule addresses several provisions in the No Surprises Act passed by Congress late last year.

Effective January 1, 2022, among other provisions, the rule:

• Bans surprise billing for emergency services. Emergency services, regardless of where they are provided, must be treated on an in-network basis without requirements for prior authorization.
• Bans high out-of-network cost-sharing for emergency and non-emergency services. Patient cost-sharing, such as co-insurance or a deductible, cannot be higher than if such services were provided by an in-network doctor, and any co-insurance or deductible must be based on in-network provider rates.
• Bans out-of-network charges for ancillary care (such as for an anesthesiologist or assistant surgeon) at an in-network facility in all circumstances.
• Bans other out-of-network charges without advance notice. Healthcare providers and facilities must provide patients with a plain-language consumer notice explaining that patient consent is required to receive care on an out-of-network basis before that provider can bill at the higher out-of-network rate.

Many parts of the No Surprises Act, including the independent dispute resolution process, the good faith estimates and advanced explanation of benefits, provider directories, and continuity of care are not addressed in this initial set of regulations.

It does not apply to Medicare or Medicaid, since both already contain balance billing protections.The interim final rule will be published in the July 13 Federal Register. The rule will be open for public comment for 60 days after it is published.

Details of the Interim Surprise Billing Rule

In this document, the American Hospital Association (AHA) has summarized the major provisions of the 411-page interim final rule. It is especially worth noting the following:

Interaction with State Law:
Massachusetts also passed a surprise billing law in January 2021 that has not yet been implemented. Thus, there are continuing questions around how the two laws will interact. In general, the interim final rule states that its provisions apply to all forms of commercial coverage (e.g., individual market, self-insured, fully insured) except in instances where states have surprise medical billing protections in place for state-regulated plans. In those instances, the state law and processes would apply. The federal departments address the specific situation where a state has permitted a plan regulated under the Employee Retirement Income Security Act (ERISA) to opt into the state’s process and permit this practice to continue. They also address a number of different scenarios to help identify when state versus federal law would apply, such as when the health plan license and the provider are in different states.

Requirements Under Prudent Layperson Standard:
The departments recognize that some commercial health plans have implemented policies that restrict coverage for emergency services that are inconsistent with the prudent layperson standard and have implemented policies to deny coverage based on the patient’s final diagnosis or using general plan coverage exclusions. The departments unequivocally state that these policies are inconsistent with the requirements of the No Surprises Act, as well as the prudent layperson standard established by the Affordable Care Act. This means that policies such as United’s restrictions on coverage for emergency room care would be prohibited.

Consent Process to Waive Balance-Billing Protections:
The law allows patients to waive their balance-billing protections and consent to out-of-network charges under certain limited circumstances. The rule directs the departments to establish a process to obtain patient consent for balance billing. Providers can't use this for emergency services, in instances where the patient cannot give voluntary consent or is unable to be transferred, or for some ancillary services.

Providers Must Disclose Balance-Billing Protections:
Providers will be required to post publicly to inform patients about their surprise-billing protections.

- See the full MHA article.

7/21