The No Surprises Act (NSA) went into effect on January 1, 2022. The federal law protects patients who are unknowingly treated by out-of-network physicians while seeking care at a hospital or clinic that is in-network with their health plan. Prior to the NSA, patients who went to the emergency room or had surgery often discovered, after-the-fact, that the anesthesiologist or emergency medicine physicians were not affiliated with the same networks as the hospital.
Surprised medical bills from out-of-network physicians are far less of a problem nowadays. However, American patients are still sometimes surprised by medical bills they did not expect. This is often because they thought the bill would be covered by their health plan. This occurs for numerous reasons (more on this below). A recent study by the Commonwealth Fund found that many patients are simply billed in error. USA Today has a summary:
The survey, from the Commonwealth Fund in New York City, found 45% of working-age consumers last year were erroneously billed, however, fewer than half of those patients challenged their health insurance company or a medical provider about the unexpected charges.
More than 1 in 3 consumers who contested surprise medical bills said the extra work paid off and the costs were reduced or eliminated.
Many people don’t realize they can question a bill they do not understand or challenge a bill they believe should have been covered by their health plan.
More than half of the people who said they didn’t challenge medical billing errors said they were unaware they had the right to do so. The survey said consumers under 50, people with low-to-moderate incomes and Hispanic residents were the least likely to challenge a medical bill.
Another 17% of consumers said their insurance plans denied coverage for a doctor-recommended medical service or procedure. When an insurance plan refused to cover care, 47% of consumers said their health condition worsened.
So how do you challenge a bill you suspect was sent in error? Business Insider interviewed a young woman with a chronic illness. She advised readers to not assume a bill is their responsibility just because they received it in the mail, saying:
I became an accidental expert at investigating medical bills — and getting them reduced — during a few years of doctor’s visits for a chronic condition. I get health insurance through my employer, but I was still being asked to pay dozens of large charges myself. Luckily, by doing three things, I didn’t have to pay over $4,000 that I was going to be billed for.
Cassandra Cloutier identified three things she does to reduce surprise bills.
- Check the order from your physician against the services you were billed for.
Ms. Cloutier received a bill for a diagnostic scan that had not been ordered by her doctor. It was a service that often accompanies another diagnostic scan that was ordered by her physician. Basically, looking for different things on the same scan. The insurance company would not pay for it as it was not medically necessary. Cloutier discovered it had not been ordered by her physician and alerted the medical billing department. The charge had to be removed since the service wasn’t authorized.
- Check whether you’re being reimbursed properly by your insurance company
Ms. Cloutier tracked her reimbursement checks carefully. An out-of-network physician was authorized through her insurer, but she had to pay the bills herself and seek reimbursement. Thousands of dollars in payments had been sent to the physician’s office instead of her. After she proved the physician had been paid by her the insurance company reissued the checks to her.
- Confirm that your physician correctly billed your insurance
After a series of charges were rejected by an insurer and billed to her, she discovered that the medical office did not have the correct health insurance information. Once that was corrected, she was able to have the charges rebilled to her insurer.
Surprise medical bills are still common, they’re just not from out-of-network providers. Patients should scrutinize their bills carefully and challenge those they believe they do not owe. Various studies have found that when patients challenge a denied bill or a denied service, they are often able to get the decision reversed. In addition, there are a lot of errors made by hospitals, clinics and health insurers.