Health plans

Banning ‘surprise billing’ in health plans is a work in progress, analysis finds

The ban on “surprise billing” in health insurance programs – including the federal FEHB program for employees/retirees – which came into force at the beginning of this year is not absolute and its implementation is still ongoing, according to the Kaiser Family Foundation.

The foundation, which produces reports and recommendations on health insurance matters – and which is not associated with healthcare provider Kaiser – said the law change “creates important new protections” against unexpected costs for unknowingly receiving care from providers outside their plan’s network.

Such billing may occur, for example, in emergency rooms and other urgent care facilities when enrollees do not have time to check whether facilities are in-network, or when receiving care in an in-network facility. the share of service providers who are outside the network. The foundation found in a 2019 survey that 39% of respondents had received an unexpected medical bill in the previous 12 months, including 13% for $2,000 or more.

The No Surprises Act of 2020, passed with bipartisan support, prohibits surprise billing for emergency services, prohibits high out-of-network cost sharing for emergency and non-emergency services, prohibits out-of-network charges for attendant care (such as for anesthetist or assistant surgeon) at a network facility, and prohibits other out-of-network charges without notice.

“The law is very complex, however, setting coverage and billing standards for a specific subset of private insurance claims that could reach 10 million a year. Providers are allowed to ask consumers to waive their NSA protections in certain cases,” the analysis states.

While health carrier audits will provide some oversight of their compliance, it will involve various federal and state entities and “it remains to be seen how these new systems will work, independently and in coordination.”

“To a large extent, monitoring and enforcement will be based on complaints. To complain, however, consumers will need to understand that they should not be overcharged for emergency services or for non-emergency out-of-network services while in in-network hospitals and facilities,” he said. -he declares.

“Finally, it remains to be seen whether other tools will be used to monitor trends in the incidence of surprise medical bills, and how effectively the law can work to protect consumers from surprise bills and reduce their out-of-pocket costs,” It said.

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