Page 15 - BusinessWest January 24, 2022

Unwelcome Surprises
Efforts to Curb Unexpected Medical Bills Go into Effect
By Jodi K. Miller, Esq. and Ryan J. Barry, Esq.
Awoman injures her ankle while jog- ging and goes to the local emergency department for treatment. Despite her injury, she makes sure to go to a hospital in her health plan’s network. Some weeks later, she receives a significant — and unexpected —
out-of-network providers, some of whom then bill patients the difference between their charges and the health plan’s benefit payment for out-of- network services. These bills are often a surprise because the patient either was not able to choose an in-network provider or was unaware that the
and providers, as well as on health plans, in three key areas: emergency services, non-emergency services provided by out-of-network providers at in-network facilities, and air ambulance services. When those services are rendered, health plans must make a payment to the out-of-network pro-
viders, and patients are responsible only for the cost-sharing obligations they would have incurred had the care been provided in net- work (e.g., co-payments and deductibles).
If the provider does not accept the health plan’s payment, the plan and the provider must attempt to negotiate a reimbursement rate. If negotiations fail, the plan or the provid- er can initiate a dispute-resolution process to resolve the issue. In these cases, providers may not bill the patient more than the cost-sharing amount, and they are potentially subject to civil monetary penalties of up to $10,000 per violation if they do so.
The No Surprises Act also provides that out-of-network providers of certain scheduled services may not balance-bill patients unless the provider has given advance notice and obtained written consent from the patient. The act sets out specific requirements for the content of the
Surprise
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JODI MILLER
“This type of ‘balance’ or ‘surprise’ bill has been an ongoing issue when patients receive care from out-of-network providers, some of whom then bill patients the difference between their charges and the health plan’s benefit
RYAN BARRY ” payment for out-of-network services.
bill from an emergency department physician. While the hospital was in her health plan’s network, it turns out the treating physician was not. Her health plan paid a portion of the physician’s charges, but she is responsible for the remainder.
This type of ‘balance’ or ‘surprise’ bill has been an ongoing issue when patients receive care from
provider was out of network until after the ser- vices were rendered.
Recently enacted legislation at the federal level and in Massachusetts attempt to address this issue.
A new federal law, the No Surprises Act, went into effect on Jan. 1. The No Surprises Act imposes requirements on healthcare facilities
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