The No Surprises Act offers several protections from surprise bills. But the new law comes with two important watch-outs and a loophole insurance companies may use to eliminate your protections.
Waiving Protection from Surprise Bills
Surprise bills often come from an out-of-network provider you didn’t know was out-of-network. The No Surprises Act has some protections for these situations. However, there are times when a provider can legitimately charge you for out-of-network services. That’s where the watch-out comes in.
In order to hold you responsible for out-of-network costs, the provider must give you a written notice at least 72 hours before receiving the services. The notice must include the following:
- Written in easy-to-understand language
- Written in your region’s 15 most common languages
- List the provider’s name and services
- List in-network providers, if any, that can provide your care
- A good faith estimate of the charges
Two other important things to know:
- The notice cannot be buried in a stack of other papers you’re asked to sign
- It is not valid without your signature
You can refuse to sign the notice. If you do, the provider can cancel the procedure. The provider cannot charge you for the cancellation.
This waiver can’t be used by the types of providers you don’t choose, such as radiologists or anesthesiologists.
What if you want to use an out-of-network provider? The same notice and steps for validation apply to that situation as well. In other words, you have the choice to use an out-of-network provider. But if you do, make sure the notice is written and administered in accordance with the requirements listed above.
Post-Stabilization Watch-out
You can be responsible for out-of-network charges if you are stabilized after an emergency service, but you’re not well enough to be discharged.
Let’s say you receive emergency care at an out-of-network hospital. The No Surprises Act protects you from those out-of-network charges. But then you’re stabilized. However, you still need in-hospital care. This is called post-stabilization.
You will be responsible for your out-of-network post-stabilization charges if the following criteria is met:
- Your provider determines you can travel to an in-network facility
- You can get to that facility using non-emergency or non-medical transportation; such as, a cab or a bus
- You can consent (you’re well enough to understand and respond to the proposed moved)
- The provider gives you an estimate of the out-of-network fees, AND
- You consent in writing
The move might just be from one building to another on the same campus. Or it could be something more significant. In any case, make sure you, a family member or friend, or your advocate understand these requirements. And make sure they are done completely and correctly.
Insurance Companies’ Loophole
It’s too soon to tell if this loophole is one that insurance companies will be jumping through. But it is a possibility you need to know about it.
The most basic protection of the No Surprises Act is to protect you from surprise bills for emergency services. It’s the “emergency” part of the protection that leads to the potential loophole.
What if your insurance company says your situation was not an emergency? That’s what happened to this couple. Their insurance company, Cigna, said the out-of-network neonatal intensive services for their twin newborns did not qualify as an emergency. With no protection from the out-of-network charges, the parents received a bill for $80,000.
In that case, the insurance company needed documentation from the hospital supporting the emergency care. For months the paperwork was either not sent or not received. Who knows which it was since the insurance company and hospital were pointing fingers at each other.
In the end, Cigna got the paperwork and processed the claim as an emergency. Thus reversing the huge out-of-network bill. But it took over a year and an insurance advocate to get it resolved.
Getting Out of a Loophole
There is nothing you can do to prevent this loophole from happening. But here are four things you can do to get out of a loophole:
- Request your medical records. Hopefully they’ll prove your situation was an emergency.
- Be patient and persistent if the hospital doesn’t initially send your records. Keep calling until you get them.
- File an appeal with your insurance company. Include your medical records as proof of the emergency.
- If the appeal fails, file a complaint with one of these agencies:
As always, be aware of your rights and know what you’re signing before you sign any document.