Health Matters <--KICKER
More than once, patients have asked whether I was “in-network” for their insurance plan. It’s five minutes before I’m about to put them to sleep for life-saving surgery, and the prospect of getting a hefty bill from me worries them more than their fractured limbs or burst appendices. Fortunately, I belong to the same health system that runs my hospital, so I reassure the patients that if the hospital is in-network for them, then so am I, and I swiftly wheel them into the operating room.
“Surprise billing” is a major cause of medical debt. It happens when patients receive care from out-of-network providers, often unknowingly and involuntarily, and their insurance plans cover none or only a small portion of the cost of care. It’s also called “balance billing,” because the providers are requesting the patients to pay for the difference between the insurer’s payment and what they charge — which is usually much higher than the in-network price. Surprise billing has affected one in five Americans, amounting to $40 billion each year. Patients and families see their credit destroyed, even driven to bankruptcy, despite having health insurance.
Thirty-two states, including Illinois, have already enacted laws barring surprise billing to varying degrees. Several bipartisan federal bills drafted in fall 2019 were shelved with the sudden arrival of COVID. Finally, the issue was re-addressed in the pandemic relief package passed by Congress at the end of 2020. Nicknamed the “No Surprises Act,” this new legislation protects patients by removing them from the billing disputes between providers and insurers.
The law requires that insurance plans provide coverage for patients receiving out-of-network care under two circumstances. The first is emergency care. If you come to an out-of-network facility for a medical emergency, all the care you receive until you’re discharged or stabilized enough to be transferred is covered at the in-network benefit level.
The second is care by out-of-network providers at in-network facilities. Most hospital-based specialists, whom the patients don’t know and can’t choose, fall into this category, including anesthesiologists, neonatologists, intensivists, radiologists, and ancillary professionals such as surgeon’s assistants. If you come to an in-network hospital for surgery and are put to sleep by an out-of-network anesthesiologist, you won’t pay more than your share for in-network anesthesia services.
Importantly, the law prohibits providers from sending bills to patients in the above situations.
Excluded are out-of-network providers the patients choose to see. To clarify, the providers must notify the patients of their network status and have the patients sign a consent ahead of time. Out-of-network providers also need to give patients a “good faith” cost estimate, and a list of in-network providers who offer similar services, so the patient can make informed decisions….