New laws protect against surprise medical bills

A pair of new state and federal laws aims to end a problem millions of Ohioans and Americans face each year: discovering too late that a doctor or medical facility they had no choice but to use did not accept their insurance, leaving them on the hook for hundreds or thousands of dollars.

The laws - Ohio House Bill 388 and the federal No Surprises Act - were created to address what's commonly referred to as surprise medical bills. The Ohio law took effect Jan. 7, while the No Surprises Act took effect Jan. 1.

Surprise medical bills

Surprise medical bills occur when a person with health insurance visits an in-network facility but inadvertently receives out-of-network care, Mercer Health Community Hospital Chief Financial Officer Jon Dingledine said.

Surprise billing, also known as balance billing, is a medical bill from a healthcare provider billing a patient for the difference between the total cost of services and the amount insurance pays toward the bill, he said.

"Patients usually, rightfully, assume services at in-network facilities will be in their insurance plan," Dingledine said.

Surprise bills often stem from emergency care, but can also come from non-emergency care, Dingledine said.

For example, Dingledine said a patient could have surgery at a hospital that accepts his or her insurance plan, but the anesthesiologist who helps in the surgery may be a contracted worker.

A contract dispute between the hospital and the anesthesiologist could temporarily make the anesthesiologist's services out-of-network, Dingledine said.

While the surgery itself is covered by insurance, the anesthesiologist's professional services are not, leaving the patient to foot an unexpected bill, Dingledine said.

In another example, a patient with severe injuries from a car accident may need to be transported by a medical helicopter from their in-network hospital to an out-of-network hospital for more advanced care.

Despite having no choice in how they were transported and who treated them, the individual's health insurance may not cover the entire out-of-network cost.

Dingledine said surprise billing is rare at Mercer Health.

The hospital employs most of its workers so many of the services are in-network, Dingledine said. The hospital also handles most of its own billing, he said.

"For example, we have a contract with a provider in the emergency room and we do the billing," Dingledine said, so the bill would be treated as in-network.

Dingledine said the hospital does have some contracted workers who may not be not in-network because Mercer Health does not handle the billing.

For example, Mercer Health contracts with Columbus Radiology, which handles its own billing, he said.

"So potentially you can go to the hospital for an MRI and the cost of doing it (would be covered)," Dingledine said. "But reading it, the professional services, could be out of network. But that's much more frequent at bigger facilities."

Dingledine noted Mercer Health is compliant with the new laws and gives notice to patients about the kind of care they are receiving and how it will be billed.

Who do the laws apply to?

The laws apply to everyone who gets insurance through their job or purchases an Affordable Care Act plan on their own, Dingledine said.

Some health insurance coverage programs such as Medicare, Medicaid and Veterans Affairs Health Care already have protections against high medical bills and surprise billing, according to the Centers for Medicare and Medicaid Services (CMS).

For people without health insurance or people who choose to pay for care without using their insurance, the new rules make sure everyone can get a "good faith estimate" of how much care will cost beforehand, according to CMS.

If an uninsured person receives a bill that is $400 or more than the "good faith estimate," they can file a complaint with CMS. Once filed, the provider can't send the bill to collections or charge a late fee until the dispute is resolved.

Dingledine added he was not aware of any retroactivity with the laws, so an individual who received a surprise bill before the laws took effect may not be able to contest the bill.

What do the laws change?

The state and federal laws combined address a few main issues: protecting consumers from surprise medical bills; understanding costs in advance to avoid surprise bills; and resolving payment disagreements.

Dingledine said the state and federal laws largely overlap.

Both Ohio House Bill 388 and the federal No Surprises Act protect patients from receiving and paying surprise medical bills above the patient's in-network rate from health care providers for emergency care or, in certain circumstances, unanticipated out-of-network care, according to the Ohio Department of Insurance.

Cost sharing amounts, which include coinsurance, copayments and deductibles, are limited to the patient's in-network amounts under the new laws.

According to CMS, the federal law bans surprise bills for emergency services, even if a patient gets services out-of-network without approval beforehand, also known as prior authorization.

It also bans out-of-network charges and balance bills for supplemental care, such as anesthesiology and radiology, by out-of-network providers who work at an in-network facility, according to CMS.

The new laws also lift the burden of payment reconciliation from consumers to health care providers and health insurers, Dingledine said. Before the laws, patients had to figure out payment reconciliation and essentially act as a middle man between the two entities, he said.

The Ohio and federal laws work together to protect consumers from air and ground ambulance surprise billing as well. The federal law applies to air ambulances, such as medical helicopters, while the Ohio law applies to ground ambulances, which include traditional ambulances.

Under the federal law, health care providers and facilities are required to give consumers an easy-to-understand notice explaining that getting care out-of-network could be more expensive and options to avoid balance bills.

Dingledine said Mercer Health has resources such as the patient accounting team, which can give patients a cost estimate for services ahead of time.

"We support people understanding those things and advocating on their behalf," he said. "All of those resources are very well intended and hopefully protect patients and they're not surprised by anything when receiving medical care."