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Transparency & Knowing the Right Questions to Ask
The No Surprise Act (NSA) is now live. What does that mean for you and your family in 2023?
We have all experienced that moment when we see a letter in the mail from a medical provider and we dread opening the envelope because we have no idea how much we are going to owe.
Thankfully, recent laws have been passed to start the process of transparency and, ultimately, affordability regarding future medical events. The No Surprise Act (NSA), which went into effect in January 2022, was established to provide federal protections against surprise medical bills.
A surprise medical bill can occur when insured consumers unintentionally receive care from out-of-network hospitals, doctors, or other providers they did not select. Studies have shown that almost 1 in 5 emergency room visits and 1 in 6 in-network hospitalizations for non-emergency care can result in a surprise bill from an out-of-network provider. The argument is that if you go to an in-network facility, all procedures done on-sight should be billed as in-network.
Studies have shown that almost 1 in 5 emergency room visits and 1 in 6 in-network hospitalizations for non-emergency care can result in a surprise bill from an out-of-network provider.
Surprise medical bills can create financial burdens for consumers when health plans deny out-of-network claims or apply higher out-of-network cost-sharing. Consumers can also face “balance billing” from out-of-network providers that have not agreed to accept discounted payment rates from a health plan.
According to the federal government, they estimate that the NSA will apply to about 10 million out-of-network surprise medical bills this year. Under the new law, the NSA will protect consumers from surprise medical bills by requiring private health plans to cover these out-of-network claims and apply in-network cost-sharing. The law applies to both job-based and non-group plans (including grandfathered plans) and prohibits cost-sharing doctors, hospitals, and other covered providers from billing patients more than in-network cost-sharing amounts (https://www.kff.org/).
A Good Faith Estimate... Is Just An Estimate
Another aspect to the No Surprise Act involves patients who are getting health insurance or healthcare treatment done as a self-pay customer. Under the NSA, patients can get a Good Faith Estimate from their provider prior to a surgery or procedure.
Ironically, I just experienced a situation regarding the NSA that I felt was worth sharing.
For over a year, my kids had been having issues with ears and ear infections and we tried all the “things” to help. As any parent knows, nothing is worse than seeing your children in pain. Knowing just how frustrated my wife was feeling over this process, I knew we needed to see a specialist and figure out a long-term plan.
Well, it didn’t take long for the ENT to confirm that tubes were going to be necessary for both kids, which is scary as a parent, but the positive was that they should both feel relief almost instantaneously.
During the process of scheduling the procedures, which we scheduled to have done on the same day, we received a Good Faith Estimate from the ENT for the physician's cost of the surgery. A Good Faith Estimate is a way for patients to know within a $400 window what they can expect their bill to be, aka, no surprises. The cost in our situation was projected to be around $450 all in, and I was happy to pay that in advance. Two weeks after the procedures, we received another bill from the same ENT for an amount of over $1,200 for the physician services, and the $450 we already pre-paid had not been applied.
A Good Faith Estimate is way for patients to know within a $400 window what they can expect their bill to be, aka, no surprises.
Seeing a 180% difference in price was not good, but the bigger problem was the Good Faith Estimate that they provided was well over the $400 difference that is allowed by the NSA regarding a Good Faith Estimate.
I was certainly “surprised” by my bill, but now the question became, what do I do next? As someone that is in the insurance industry, I am familiar with this process and know what to ask for. But I felt sorry for the average American that would have to navigate a similar situation on their own.
After calling the provider’s office, I discovered that their office doesn’t even do their own internal billing. They have a separate outsourced billing department with another ENTs office, located in an entirely different city! This obviously led to some initial confusion, but then the provider told me that I had a remaining balance ranging from the $450 to the $1,250. When I mentioned that the new bill was more than $400 above the original Good Faith Estimate, and that I was willing to either dispute this bill because of the No Surprise Act or they can apply what I have already paid as “paid in full”, I think it is safe to say that I caught them by surprise.
After some quick scrambling and several minutes on hold, they told me that they were going to reach out to the other office and have someone call me back that day. Fast forward more than 2 weeks and I still have not received a call, nor have I been able to get a final answer when I try to follow up.
Again, I am very comfortable with this situation, and I know it will get resolved, but it certainly is not convenient. I couldn’t imagine trying to navigate this on my own.
This is just one small example of why having the right system in place can protect you, and as a consumer of healthcare, you need to know what to look for. Thankfully, because the NSA was passed, I have the protection of the Good Faith Estimate on my side and will get a final resolution. To me though, the biggest takeaway is people should not try to fight these things on their own. You need someone that understands the language, and the process, of the types of questions to ask.