Medical Bill Advocate Helps with Claims Amidst New, No Surprise Act

Most Americans are not aware of the No Surprise Act, but Medical Health Advocates like Adria Gross of Medwise Insurance Advocacy are ensuring consumers are aware of their rights.

Roughly twenty percent of Americans that have used an emergency room or have been hospitalized in the United States, have received a medical bill that caught them by surprise. Nearly as many have gotten unexpected bills from non-emergency hospital stays.

These unexpected bills are more than a nuisance for many Americans because they can cause anxiety, stress, financial hardship and uncertainty. According to a KFF poll, about sixty-six percent of Americans say they worry about being able to afford unexpected medical bills and nearly half are not able to fully pay surprise bills.

Thanks to the No Surprises Act, which took effect on January 1, 2022, surprise bills will no longer exist.

The No Surprise Act is a law that passed in late 2020 providing consumers federal protection from unexpected out-of-network medical bills. In other words, bills from healthcare providers who don’t participate in the patient’s health insurance network.

Out-of-network charges happen often in emergency care, where consumers usually don’t have a choice in where they go or who provides their care. Nonemergency hospitalizations, where multiple providers may be involved in care can also create these charges. Even if a hospital participates in a patient’s insurance plan, specific providers, such as anesthesiologists or radiologists, may not. Consumers may have no say, and no idea that they’re getting care from out-of-network providers.

As of January, 2022, this has changed.

The law requires that private health insurance companies cover certain out-of-network bills and apply consumer copayments or other costs as if the care had been delivered by in-network providers. It also prohibits doctors and hospitals from charging consumers more than they would have to pay for the applicable services if the providers were in-network with the insurance company.

The No Surprises Act applies to bills for emergency services provided in hospital emergency departments, freestanding emergency facilities, and urgent care centers that provide emergency services. In addition, air ambulance transportation (not ground ambulance) and non-emergency services provided by out-of-network providers who may practice at but bill separately from in-network facilities.

How the No Surprises Act May Affect Consumers

With over a year for preparation, Hospitals and other healthcare providers have yet to get ready and the full extent of the law’s impact on consumers at this time, is unknown.

Adria Goldman Gross, a New York State-licensed insurance broker and founder of MedWise Insurance Advocacy, shows concern on how the law’s implementation will work and urges consumers to exercise caution.

“With this new law, my advice is to be sure that you never sign paperwork allowing an out-of-network provider to balance bill you,” Gross said. “You might see hundreds of thousands of dollars billed to you after completion of the surgery [or] procedure.”

Balance billing, as Gross infers, is when a provider bills the patient for the difference between the provider’s fees and the portion of those fees that insurance pays. Balance billing is not allowed for people insured by Medicare and Medicaid. However, nothing prohibited it in private insurance until the No Surprises Act.

Under this new law, patients are required to be notified by providers, as well as post publicly, their surprise billing protections.

If a consumer is asked to sign a consent form that allows the provider to balance bill, the new law requires that the provider give an estimate of charges 72 hours in advance unless the services are scheduled sooner.

Consumers can’t be asked to waive protections against balance billing in emergencies or for certain nonemergency services. Such services as ancillary services (anesthesia, pathology, radiology) associated with emergency care or diagnostic services such as radiology or labs can’t be asked to be waived, according to the law.

“Just imagine yourself being unconscious or so sick it’s almost impossible to read anything,” Gross said. Alternatively, if a consumer refuses to give consent, the provider could decline to treat them.

Individuals who are not sure what they’re signing, should ask if they’d be waiving their rights to be protected from balance billing. Gross also suggests writing on the agreement asked to sign that no payment will be made if they balance bill and to initial that statement to be perfectly clear.

The No Surprises Act rules will be left up to providers and health plans to identify which bills are affected. Meaning that getting a bill that should have been protected will have to be figured out by consumers and it will be up to individuals to hold the provider and health plan accountable.

Decisions by health plans, not to cover applicable charges can be appealed. If the initial denial is upheld, an external appeal with an objective third-party can follow.

Depending on which type of health insurance a consumer has, assistance from an appropriate regulatory authority may be available. The U.S. Departments of Labor and the Treasury, for example, are responsible for regulating self-insured group health plans. These plans are offered by many large employers.

Consumers who try to fight surprise bills and don’t succeed, or consumers needing help with their denied claims, or unpaid medical bills can turn to a patient advocate like Adria Gross, who specializes in medical billing.

MedWise Insurance Advocacy
MedWise Insurance Advocacy

562 NY-17M
United States

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Disclaimer: The views, suggestions, and opinions expressed here are the sole responsibility of the experts. No Daily Scotland News journalist was involved in the writing and production of this article.