Health care: New protections designed to shield patients from surprise billing

·5 min read

Jan. 23—New laws that protect Ohioans against many surprise medical bills are an important and bipartisan health care reform that's been years in the making, experts say.

The new federal and state laws, which took effect this month, are aimed at protecting patients who accidentally go out-of-network in an emergency or some non-emergencies, and then end up stuck with the balance between what the insurance company pays and provider charges.

About 1 in 5 emergency room visits ends in one of these types of out-of-network bills, because at a typical hospital the emergency physicians, anesthesiologists, medical helicopter staff and more might work for a staffing company or contractor.

These contractors might not take the patient's insurance, even if the hospital itself is in-network, and patients don't always know these workers might be wearing hospital badges but not be hospital staff.

Patients used to be stuck with these out-of-network bills, but the laws now require that insurers and providers directly work out the billing dispute with each other, leaving the patient out of it.

This is a significant set of protections for consumers, said John McAlearney, assistant professor at the Wright State University Boonshoft School of Medicine, who has researched health economics. Sometimes stories about high medical bills make people scared to get health care, but the new protections should help, he said.

"It should make people feel a lot better about using the health care system," McAlearney said.

The federal law alone is expected to protect patients from about 10 million out-of-network surprise medical bills a year, according to government estimates.

This change in law is a major policy shift, according to Ohio Department of Insurance Director Judi French.

"If you're in that emergency situation, you don't want to worry about where the ambulance is going to be taking you. You don't want to have to worry about 'am I going to be life-flighted or will my child be life-flighted to a hospital, where I'm going to have additional costs?" French said. "Those are things that consumers really shouldn't have to worry about. And that's the importance of this legislation."

Ohio Sen. Sherrod Brown had introduced legislation in 2017, the End Surprise Billing Act, proposing patient protections and was a supporter of the bipartisan No Surprises Act that finally passed. He said many people, including lawmakers and constituents, don't know what a surprise bill is until they get one.

"We're out in the community, with roundtables, and we started hearing these stories," Brown said.

Read waivers carefully

Some patients might be asked by a provider to sign a form that waives their rights under this new law, agreeing to receive treatment from an out-of-network health care provider and be billed the out-of-network balance.

There are caveats to these waivers. Under the law, these waivers must be signed at least 72 hours before the service. For same-day scheduled services, regulations permit consent to be given at least three hours in advance.

The new rules also state that many services are not allowed to ask for waivers, such as emergency services; ancillary services like radiology and pathology; services provided by assistant surgeons, hospitalists, and intensivists; and more.

Waiving protections could cost patients more money and patients do not have to sign. People can call their insurance company to see what in-network options they have, said Jane Peterson, president of Anthem Blue Cross and Blue Shield in Ohio.

"There is always that option of reaching out to the insurance carrier and getting a better understanding around what in-network options there are," Peterson said, adding that people will need to plan ahead to leave time for that research.

Watching for results

Ohio Department of Insurance is planning a public information campaign to make sure people know their new rights as patients.

People who still get problem bills or just have questions about how the law should work can give Ohio Department of Insurance a call and talk to an expert, at 1-800-686-1526.

"We want to hear from consumers that are still getting these bills, but the way this is supposed to work is the consumer simply won't see those bills anymore," French said.

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By the numbers: Surprise billing impact

18%: ER visits with any out-of-network charge in 2017, for people with health insurance through a large group plan

16%: In-network hospital stays with at least one out-of-network charge in 2017

39%: Insured adults younger than 65 who said they received an unexpected medical bill in the past 12 months, including one in ten who said that bill was from an out-of-network provider

Of those who received an unexpected bill, half said they were expected to pay was less than $500 overall while 13% said the unexpected costs were $2,000 or more.

Source: Peterson-Kaiser Family Foundation Health System Tracker, August 2018

If you still get a surprise bill

If you think you were sent a bill you shouldn't have to pay, first call your insurance company about fixing the error.

If this doesn't fix the problem, contact the Ohio Department of Insurance at 1-800-686-1526, consumer.complaint@insurance.ohio.gov, or insurance.ohio.gov.