In my February post I summarized the No Surprises Act that is going into effect January 2022. The Act’s main objective is to protect patients from huge surprise bills for certain out-of-network charges. Patients will only have to pay in-network rates for covered out-of-network charges.
I said I would update you as significant milestones occurred. The first milestone occurred on July 1st. That’s when the Departments of Health and Human Services (HHS), Labor, and Treasury, and the Office of Personnel Management (OPM) released their first Interim Final Rule (IFR).
What is an IFR?
The No Surprises Act didn’t include all of the necessary operational details. The IFR is the government’s’ first set of decisions (rules) regarding those details. Comments, which will be accepted for 60 days, aren’t expected to change the rules.
Most of the rules in this IFR will be effective January 1, 2022. They apply to nearly all types of insurance plans including fully-insured, self-funded, group or individual plans as well as carriers under the Federal Employee Health Benefits Program.
Here are the changes that affect consumers.
Emergency Services Protected in the No Surprises Act
Emergency rooms (ERs) have been the cause of countless out-of-network surprise bills. After all, in an emergency you rarely have the time or ability to choose an in-network facility. In addition, ERs seem to have a tendency to increase the level of severity when choosing a diagnosis code. That means they can bill you for more complicated, and thus more expensive, care than you needed. The result: you have to pay thousands of dollars for treatment of a relatively minor illness or injury.
To protect you as much as possible from emergency-related surprise bills, the IFR expanded the definition of emergency services. Beyond hospital ERs, the IFR extends protection for services provided by independent freestanding ERs including urgent care centers legally permitted to provide emergency services.
The HHS has asked for comments regarding classifying urgent care centers as emergency services providers. Therefore, the definition may change again before the No Surprises Act goes into effect.
Additional ER Protection
The IFR further expanded patients’ protections by prohibiting insurers from denying ER bills based solely on your diagnosis at time of discharge. For example, you’re having chest pains. You go to the ER because you think you’re having a heart attack. It turns out that you just had indigestion. When reviewing your claim for payment, your insurer doesn’t consider the fact that you had chest pains. Instead, they only look at the final diagnosis of indigestion. They deny the claim because indigestion is not life-threatening; you should have gone to an urgent care center or other less expensive facility.
Because the insurer found a way to avoid paying for your ER visit, you’re left with the huge bill. I think it’s hardly coincidental that, as I discussed in an earlier post, United HealthCare suddenly postponed the use of ER diagnoses to deny coverage. Perhaps this expanded protection means that United HealthCare’s new punitive policy is permanently off the table.
Post-Stabilization Services
You receive post-stabilization services once you’re stabilized following an emergency Under the IFR, you have some protection from out-of-network post-stabilization charges. But the protection does not apply to all situations. You lose protection if:
- The treating physician determines you are able to travel using nonmedical transportation to an in-network facility
- The in-network facility is within a reasonable distance
- The provider gives you appropriate notice in a language you can understand
Non-Emergency Services at In-Network Healthcare Facilities
When you receive treatment at in-network facility, you cannot be charged out-of-network rates from non-network providers or supplier. This protection covers areas such as anesthesiology, radiology, and pathology.
The IFR includes ambulatory surgery centers in the definition of “healthcare facility.” That’s important because the number of ambulatory surgery centers is on the rise. Doctors and venture capitalists have discovered these centers can be big money makers. If the treating physician owns the surgery center, then he gets the profits from related “facility charges.” That income stream doesn’t happen when surgery takes place in a hospital.
What’s Next for the No Surprises Act
HHS and other government agencies will be writing additional rules for other parts of the legislation. Two such items are price comparison tools and the Independent Dispute Resolution process for insurers and providers to determine which of the two will pay the out-of-network bill. In addition, HHS will be creating a consumer complaint process for potential No Surprises Act violations. Check this space for updates as they occur, with a focus on what is most important for you, the health care consumer.
Meanwhile, in my next post I’ll tell you what you need to know in case a provider or facility asks you to waive your protection from out-of-network bills. It’s legal for them to do that. But you have the right to refuse to waive your protection. I’ll tell you what you need to know about their responsibilities and your rights. That way you can make the best choice for your needs.