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Surprise medical bills are coming to an end

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Starting next year, off-grid healthcare providers can no longer ambush patients with an unexpected and sky-high bill. Instead, doctors will first need the patient’s consent to charge an off-grid rate. “People generally thought surprise medical bills were unfair. There is an element of blindness, ”explains Daniel Klein, president and CEO of the patient rights group of the Patient Access Network Foundation. The reform could also reduce health insurance premiums.

The No Surprises Act, passed by Congress late last year, prohibits providers from charging patients out-of-network rates for emergency care and ancillary services., such as anesthesia, administered during scheduled procedures at network facilities.

Specialties, such as anesthesiology, where hospital patients have little say over who treats them, have long been a sensitive issue. “You don’t even know your doctor’s name until the bill comes in,” says Karen Pollitz, senior researcher at the Kaiser Family Foundation, a nonprofit organization that studies health policy. From 2022, insurers will have to treat these off-grid services as if they were on-grid on a patient’s bill. Suppliers and facilities can be fined up to $ 10,000 per violation.

For scheduled procedures, some off-network providers in network facilities may charge the highest rates if they give the patient an estimated bill at least 72 hours in advance and the patient consents. For procedures scheduled within this 72 hour window, the patient should be informed of the higher cost on the day of the appointment. The law also applies to air ambulances but not to ground ambulances, which are more complicated to regulate, Pollitz says. The legislation will not affect Medicare or Medicaid, as these programs already prohibit “balance billing,” that is, when a patient has to pay the difference between the doctor’s bill and what the insurance will pay.

“This law should take some of the anxiety out of patients,” says Erin Duffy, a fellow of the Schaeffer Center for Health Policy and Economics at the University of Southern California and associate policy researcher at Rand Corp., a think tank. . “You could be a patient who planned a procedure and you did your research to select a surgeon and a network hospital. But there was still a high risk that someone involved was out of the network and you could get a balancing bill. Now this fear must be fought.

According to a study published in the medical journal, around 42% of inpatient admissions had at least one request submitted by an out-of-network physician in 2016, up from 26% in 2010, JAMA Internal Medicine. Off-grid costs also increased over this period, from an average of $ 804 to $ 2,040.

Although more than two dozen states have passed laws to regulate surprise medical billing, they exclude self-funded insurance plans favored by large employers. These plans, governed by federal law, cover more than 60% of private policyholders.

When the new law comes into force, disputes over these bills will be settled between the insurer and the health care provider, and if both parties cannot come to an agreement, the case will go to arbitration. How the arbitrators decide will likely affect health insurance premiums. The Congressional Budget Office predicts that the law could reduce bonuses by up to 1% because some suppliers are paid less.

But the referees can also side with the doctors. “If the vendor continues to win, they will continue to pay the higher amount,” says JD Piro, US national health solutions manager for Aon, which provides retirement and health care products to employers. If this happens often, Piro says, the premiums will go up.

Advocates will need to educate patients about the new law, says Christopher Garmon, assistant professor of health administration at the University of Missouri-Kansas City. “It’s a problem you might run into: Suppliers send invoices and consumers don’t know they’re protected,” he says. “They can pay for it without knowing they don’t have to.”

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