Most Uncovered Healthcare Costs Now Illegal Under the ‘No Surprises Act’

It happens to millions every year.

They have a medical emergency and assume their health insurance will cover the costs.

Then a month or so later they receive bills for the cost of “out-of-network” care.

In the midst of an emergency, one usually doesn’t have time to hop online and check if the paramedics are “in-network.”

When those paramedics are transporting someone to the nearest emergency room, it would be a little unrealistic to expect him or her to have to first determine if the insurance provider covers every medical professional at the hospital.

When one is having surgery and the doctor performing it is in-network but the anesthesiologist isn’t, there really isn’t anything one can do.

This type of “surprise billing” was part of the catch-22 of having health insurance in America.

Until last week.

After a significant delay in Congress, the “No Surprises Act,” which bans most unexpected medical charges from out-of-network providers, took effect January 1.

According to an HHS press release published Monday:

“For people who have health coverage through an employer, a Health Insurance Marketplace®, or an individual health plan purchased directly from an insurer, the rules that took effect January 1, 2022:

    • Bans surprise bills any time you receive emergency care, and require that cost sharing for these services, like co-pays, always be based on in-network rates, even when care is received without prior authorization.
    • Bans surprise bills from certain out-of-network providers if you go to an in-network hospital for a procedure. This means cost sharing for certain additional services during your visit will generally be based on in-network rates.
    • Requires providers and facilities to share with patients easy-to-understand notices that explain the applicable billing protections and who to contact if they have concerns that a provider or facility has violated the new surprise billing protections.

For people who do not have health insurance or pay for care on their own (also known as ‘self-paying’), the rules that took effect January 1, 2022 require most providers to give a ‘good faith estimate’ of costs before providing non-emergency care.

“The good faith estimate must include expected charges for the primary item or service, as well as any other items or services that would reasonably be expected. For an uninsured or self-pay consumer getting surgery, for example, the estimate would include the cost of the surgery, as well as any labs, other tests, and anesthesia that might be used during the procedure.

“Uninsured or self-pay consumers who receive a final bill that exceeds the good faith estimate by $400 or more can dispute the final charges.”

HHS Secretary Xavier Becerra said:

 “The No Surprises Act is the most critical consumer protection law since the Affordable Care Act. After years of bipartisan effort, we are finally providing hardworking Americans with the federal guardrails needed to shield them from surprise medical bills. We are taking patients out of the middle of the food fight between insurers and providers and ensuring they aren’t met with eye-popping, bankruptcy-inducing medical bills. This is the right thing to do, and it supports President Biden’s vision of creating a more transparent, competitive and fair health care system.”

According to federal estimates, the measure will eliminate about 10 million surprise bills a year.

USC-Brookings Schaeffer Initiative for Health Policy assistant director, Loren Adler, explained:

“The No Surprises Act is really one of the biggest consumer protections to pass in recent decades. Now when patients go to the hospital for an emergency or for elective planned care, like a surgery, they no longer have to worry about getting a surprise out-of-network bill.”

A Department of Health and Human Services (HHS) report released in November calculated patients are responsible for, on average, more than $1,200 for anesthesiologists, $2,600 for surgical assistants, and $750 for childbirth-related care.

It is now illegal for providers to bill patients more than in-network costs insurance covers.

The only exception is for ground ambulance transport.

Centers for Medicare and Medicaid Services (CMS) Administrator, Chiquita Brooks-LaSure, said:

“The No Surprises Act offers significant relief to people across the country, and reinforces our fundamental belief that no one should go bankrupt when seeking necessary care. We are making it easy for consumers to know and understand their rights under the law, including what they can do if they receive a surprise medical bill. Consumers will not only benefit from these rights, but also will be empowered with the knowledge to address potential violations.”

According to credit monitoring agency Experian, mounting medical costs account for the largest share of Americans’ debt, amounting to $140 billion, much of it due to surprise bills.

While a Medicare-for-All single payer-type healthcare system would eliminate both surprise bills and subsequent legislation to combat it, this is a step in the right direction.

A 2018 Reuters-Ipsos poll shows 70% of respondents favor a single-payer national healthcare system, and over 100 Democratic lawmakers support the “Medicare for All Act of 2021.”

Right now, combining Medicare, Medicaid, insurance premiums, and out-of-pocket costs, we are expected to spend about $52 trillion on health care during the next decade.

But Medicare-for-All would eliminate premiums and out-of-pocket costs, reducing the price tag to between $20 trillion and $36 trillion over the same period.

According to the nonpartisan Congressional Budget Office, Medicare-for-All could save the country up to $650 billion per year.

A recent report from The Commonwealth Fund confirms the U.S. ranks dead last compared to 11 other wealthy countries in four out of five areas pertaining to access to care, process, administrative efficiency, equity and outcomes.

Image credit: Bermix Studio via Unsplash

Ted Millar is writer and teacher. His work has been featured in myriad literary journals, including Better Than Starbucks, The Broke Bohemian, Straight Forward Poetry, Caesura, Circle Show, Cactus Heart, Third Wednesday, and The Voices Project. He is also a contributor to The Left Place blog on Substack, and Medium.