Health insurance is supposed to cover you in times of need so when the unexpected happens, you don’t have a massive bill to worry about. But that’s not always the case.
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Despite the No Surprises Act, which passed in 2022 and aims to protect patients from surprise bills, some are still hit with unforeseen hefty medical expenses. To help avoid being caught off-guard, here’s what to know about surprise billing, according to healthcare experts.
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No Surprise Act
The No Surprise Act is designed to protect patients who are treated at in-network facilities, but unknowingly received medical care from healthcare providers and emergency services that are out-of-network like an anesthesiologist or an ambulance ride.
If you have health insurance through your employer or private healthcare you’ve purchased on your own, you are likely protected from surprise bills from the No Surprise Act, but per the U.S. Department of Labor, exceptions include:
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Short-term, limited-duration insurance plans
Excepted benefits plans (such as standalone dental and vision coverage)
Retiree-only plans
Account-based group health plans
The U.S. Department of Labor also said patients are covered for the following:
Most emergency services (including emergency mental health services)
Non-emergency services from out-of-network providers at certain in-network healthcare facilities (hospitals, hospital outpatient departments or ambulatory surgical centers)
Services from out-of-network air ambulance service providers
What Is a Surprise Bill?
Before the No Surprise Act, an unexpected bill could happen to anyone. Surprise bills typically occured when out-of-network doctors are brought in, particularly for emergencies or services at an in-network facility.
“I’ve had cases where a patient has selected an in-network hospital and then, unexpectedly, finds themselves confronted with an out-of-network anesthesiologist and several weeks later, a bill for $3,000 to cover the payment to the anesthesiologist,” explained Jeremy Gurewitz, co-founder and CEO of Solace Health.
“It’s disorienting, financially jarring — and let’s be honest, it’s unfair,” he said.
The No Surprise Act Isn’t Bullet Proof
According to Karim Hachem, founder and CEO of the healthcare advocacy organization Suade Health, a surprise bill still happens once a year for the average American, especially with emergency care transportation.
“Ground ambulance services are usually entirely exempt from this act or private-pay out of network procedures which are often exempt from this act entirely, but people may not know this,” he said.
And the patient is on the hook for whatever the insurance won’t cover, which can be pricey.
“These bills can be quite sizable, since insurance will cover very little to nothing on them depending on the plan (most plans, even PPOs, cover very little when it comes to out-of-network services, as they limit what they reimburse you to the CMS’s Medicare fee schedule),” Hachem explained.
While the No Surprise Act does protect patients, it’s not perfect.
“This law applies to individuals with health insurance regulated at the federal level. However, if your health insurance is regulated by your state (and your state has not enacted similar protections) you may still be at risk of receiving a surprise bill,” said Joe Saad, M.D., certified physician executive (CPE), fellow in the American College of Physicians (FCAP) and governor at the College of American Pathologists.
What To Know About Surprise Bills
Staying informed is key to avoiding a surprise bill. A facility in-network doesn’t mean all of its providers are approved by your insurance.
“Many insurers increasingly use narrow networks of physicians, hospitals and other providers, which can make it difficult for patients to access in-network care, even when they seek treatment at an in-network facility,” Dr. Saad explained.
“Despite the No Surprises Act, some insurance plans have adopted new tactics that may still lead to unexpected costs, shifting more financial burden onto patients,” he added.
How To Protect Yourself
Don’t just take a surprise bill-fight it. Talk to the insurance company and oftentimes they will work with you. Also ask if all the providers are in your network.
“When it’s feasible, obtain a written estimate in advance. They are mandated at many facilities under the current law,” Gurewitz said.
“One of our teammates helped a patient contest a $4,700 out-of-network ER bill just by asking for the provider to prove that it had provided a reasonable estimate. They could not and the charge was dismissed,” he added.
The No Surprise Act does shield patients from surprise bills, but always be alert when it comes to providers to ensure they’re in-network.
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This article originally appeared on GOBankingRates.com: You’re Covered (Until You’re Not): The Truth About Surprise Billing
