Los Angeles resident Betty Chow had her cervical disc replaced in August 2020 at a surgery center that is part of her Anthem Blue Cross PPO network.
Thirteen months later, she was caught off-guard by a nearly $2,000 bill from an anesthesiologist on the surgical team without a contract with her PPO or preferred provider organization.
Chow, a 35-year-old veterinarian, said she discussed the bill with her registered nurse boyfriend.he told her a California law The act, which went into effect in 2017, prohibits out-of-network healthcare providers working at in-network facilities from providing such “surprise bills.”
Unfortunately, the law does not protect Chow or nearly 6 million Other Californians who get health insurance through employers who pay for employee medical bills from their own coffers. These “self-financed” programs are regulated by the U.S. Department of Labor and thus fall outside the reach of state law.
But a federal law that went into effect Jan. 1 closes that gap in the more than 100 million people in such health plans nationwide, including nearly 6 million Californians.it covers millions of 32 states There are no laws against accidental acts or laws that provide only partial protection.
new federal law, no surprise bill, also protected nearly 1 million Californians not covered in 2009 California Supreme Court ruling This prohibits emergency room doctors and other emergency service providers from billing HMO patients for out-of-network charges not paid by insurance companies — a practice known as balance billing.
“Millions of Californians will now be protected from these bills that are not only unfair but put the economic security of families at risk,” said Anthony Wright, executive director of the California Health Channel, a consumer advocacy group.
Now is the time. The surprise bill has been causing financial pain to millions of Americans for far too long.
When patients are seen by an out-of-network provider they didn’t choose, it’s often a double whammy: They pay more out-of-pocket — even if their health plan covers some out-of-network care — and they may later pay more from the provider Received balance bills totaling thousands of dollars.
research shows Such unexpected bills are common among the nearly 200 million U.S. residents enrolled in private health plans.
A 2020 study found that 20% of privately insured patients undergoing elective surgery at hospitals in their insurance network received unexpected bills from providers not in their insurance network. Anesthesiologists’ bills averaged $1,219. Surgical assistants’ bills are, on average, more than double that.
“When patients pay their insurance premiums, they assume — I believe quite the assumption — that they will be financially protected,” said Katie Berg, director of federal affairs for the Leukemia and Lymphoma Society.
The No Accidents Act covers all private policyholders in employer-sponsored and personal/family health plans. Medicare and Medicaid already protect their enrollees from nasty billing surprises.
The new federal law, largely in line with California’s, prohibits non-urgent care from out-of-network providers at in-network facilities and equalized billing for most emergency room care at any facility. Insurers must pay for these services at the in-network rate, and providers may not charge patients any amount in excess of this. Providers and health plans must negotiate how much the plan will pay to keep patients out of competition.
Federal law also protects weird bill From the out-of-network air ambulance service.One California law The same goes for the Act, which came into effect in January 2020. But it does not cover millions of people in federally regulated health plans and is vulnerable to possible legal challenges as it could conflict with the 1978 deregulation of airlines, which included air ambulances.
Where its provisions are stronger, federal law will prevail over state law.
What about law enforcement? Loren Adler, associate director of health policy initiatives at USC-Brookings Schaeffer, said the federal government will defer to states in cases involving state regulatory programs as well as federal regulatory programs if the complaint targets providers. . But he said the federal government would step in if states refuse or fail to enforce the law.
Federal health officials are sending Letter to each state governor on enforcement.
California has strict laws against unexpected billing and certainly has the means and experience to enforce it, although it has not seen a large number of cases. Department spokeswoman Rachel Arrezola said the managed care sector resolved 1,006 consumer complaints about balance billing over the past four years, 467 of which were provided to enrollees Nearly $1 million in total reimbursement.
Of course, not all bills that surprise patients are regulated by state or federal law. Sometimes people owe more deductibles than they thought, or their cost-sharing is higher than they realize, or their procedure isn’t in their health plan, or the facility they choose isn’t in their network .
So, step up your insurance policy. Find out what and who it covers, what facilities are in the network, what your out-of-pocket costs are, and how much your deductible still has to pay.
This will help you determine if the bill is illegal. There will still be illegal bills – because people will make mistakes. Some medical professionals behave dishonestly.
When you get your bill, don’t pay it right away. ask questions. Compare this to the description of benefits you get from your insurance company – if you haven’t received it yet, wait. If what your provider and your health plan say is inconsistent, give them two calls and try to resolve it.
Don’t be discouraged if this doesn’t work. You can file a grievance with your health plan. If this does not resolve your issue, please contact Managed Care to file an appeal, either on their website (www.healthhelp.ca.gov) or call 1-888-466-2219.The department also has a Fact Sheet This might answer some of your questions about California’s accidental billing laws.
The federal government has launched a website (www.cms.gov/nosurprises) This may answer many of your questions about the No Surprise Act and enable you to file a complaint or dispute a bill. You can also contact the federal No Surprise Help Desk at 1-800-985-3059.
If you’re just confused by medical bills, or don’t have the confidence to compete on your own, the Healthy Consumers Alliance is a great resource.Find an office near you by www.healthconsumer.org Or call 1-888-804-3536.
Chow, a Hong Kong native who has worked as a patient on the single-payer system locally and in the U.K., said she was confused by the U.S. system, “where you pay for health insurance, but then you have to pay more.”
Although the California law doesn’t protect her from the anesthesiologist’s $2,000 bill, and the new federal law isn’t retroactive, she appears to be heading for a happy ending.
After 3 collection attempts by the anesthesiologist and several calls with Chow, Anthem agreed to reduce the bill to $83 and update the anesthesiologist’s billing office. That hasn’t happened yet, but Chow is hopeful.
“I don’t really understand what I’m responsible for,” she said, “except that $83 is well below $2,000.”
This story is made by KHN, publish California Healthline, the editorial independent service of California Healthcare Foundation.
KHN (Kaiser Health News) is a national newsroom that provides in-depth news coverage on health issues.Along with policy analysis and polling, KHN is one of the top three operating programs in the U.S. KFC (Kaiser Family Foundation). KFF is a donating non-profit organization that provides information on health issues to the state.
Photo: fizkes, Getty Images
