According to the American Journal of Public Health, nearly 67 percent of personal bankruptcies in the United States are tied to medical expenses. Fortunately, the days of surprise medical bills are largely coming to an end thanks to state action and a new federal law.
Imagine that you are working on a home improvement project when you fall off a ladder, hitting your head and breaking your arm. Fortunately, your injuries are not life threatening, but you require immediate care at the nearest emergency room. Upon arrival, your treatment includes imaging and radiology services, as well as minor surgery to repair your broken arm. While this has been a traumatic experience, thankfully you have a health insurance plan that will cover the expenses of this ordeal, right? Well, maybe not.
What if the doctor who performed the surgery was in your health plan’s network, but the anesthesiologist or the assistant surgeon who helped the doctor are out of network? Situations like this could make you one of the thousands of Americans who will be stuck with a “balance” or “surprise” medical bill.
What is surprise billing? Normally, most commercial health plans require or prefer consumers to use in-network providers, which are health-care professionals and facilities that contract with health insurance plans to provide lower priced services in exchange for being part of the health plans’ network. Surprise billing happens when the health provider bills the patient for additional amounts after the insurance company pays its portion of the bill. Out-of-network physicians, not bound by contractual, in-network rate agreements, have the ability to bill patients for the entire remaining balance, up to their full charge amount. These out-of-network providers often include surgical assistants, anesthesiologists, pathologists and radiologists. It can happen for both emergency and non-emergency care.
Part of what makes surprise billing so pernicious is that patients often have no idea that the facility or provider is out of network until they receive the bill. In many cases, services are blended among providers who are in and out of network, or they occur in an emergency situation where care is required at the closest health-care facility. In worst-case scenarios, you might be incapable of choosing an in-network emergency care provider without risking health or life.
Fortunately for Granite Staters, New Hampshire has been at the forefront of protecting consumers against surprise bills. In 2018, at the urging of Gov. Chris Sununu and the N.H. Insurance Department, the state Legislature passed legislation prohibiting out-of-network anesthesiologists, pathologists, radiologists and emergency physicians from “surprise billing” a commercially insured patient when the care was provided at an in-network hospital.
Now, the newly passed federal No Surprises Act will extend those protections and end the practice of surprise billing in most aspects of commercial insurance beginning on Jan. 1, 2022. Between state law and the federal No Surprises Act, consumers with either a fully or self-insured health plan will have protection. Passed with bipartisan support in Congress and signed by President Trump, the No Surprises Act makes it illegal for health providers to bill patients at higher rates than in-network cost sharing (copays and deductibles) in their current health plan. If a dispute arises over a balance billing issue, the No Surprises Act removes the patient from the argument and provides a dispute resolution process for the health-care provider and the insurance company to find the appropriate cost which the insurance plan will then cover.
The federal government anticipates that states will be the predominant enforcement entity of the No Surprises Act and the N.H. Insurance Department is ready to undertake that responsibility. As always, we are working hard to provide information to Granite Staters that details the protections they are now afforded under state law and the No Surprises Act.
The No Surprises Act — like much of the world of insurance — is complex, and the Insurance Department is here to help consumers every step of the way. We have informational documents published on our website www.nh.gov/insurance/consumers/documents/20211210-nsa-faq-consumers-producers.pdf that explain the details of the law and its impact on insurance companies, health-care providers and patients. We encourage the public to review these documents prior to Jan. 1, 2022. As always, consumers with questions can contact us at 603-271-2261 or firstname.lastname@example.org.