Network based systems

Off-grid emergency medical bills banned on January 1

Patients who may have been surprised with a large bill while going to an off-grid emergency room will soon enjoy some protection.

WASHINGTON – The video above is from April 2021.

The Biden administration put the finishing touches on Thursday to protect consumers from so-called “surprise” medical bills. The ban on charges that hit insured patients at some of life’s most vulnerable times will take effect on January 1.

Patients will no longer have to worry about having a huge bill as a result of a medical crisis if the nearest hospital emergency room is outside of their plan’s provider network. assurance. They will also be protected against unforeseen costs if an out-of-network clinician participates in a surgery or procedure performed at a network hospital.

The rules released Thursday detail a key part of the new system: a behind-the-scenes dispute resolution process that hospitals, doctors and insurers will use to haggle over fees. When an insurer and a service provider disagree on a fair payment, either party can initiate a 30-day negotiation process. If they still can’t come to an agreement, they can take the matter to an independent arbitrator.

There is also a new way for uninsured people and some self-paying patients to get a cost estimate following an emergency procedure.

“We hope to give a sigh of relief to people who have been caught off guard by the billing,” said Xavier Becerra, Secretary of Health and Social Services.

Surprise medical bills have been a common problem for people with health insurance, all the more irritating since most patients would have thought they were protected. Fees ranging from hundreds to tens of thousands of dollars came from doctors and hospitals outside the patient health insurance plan network. It is estimated that around 1 in 5 emergency room visits and 1 in 6 hospitalizations triggered a surprise bill.

Although many states have already limited surprise billing, federal action was needed to protect patients covered by large employer plans, which are regulated nationally. A 2020 law signed by then-President Donald Trump set out a bipartisan strategy to address the issue, and the Biden administration provided critical details.

The idea was to take patients and their families out of the financial equation by limiting what they can be billed for off-network services to fees based on network fees. This amount is included in their annual deductible in the network.

The new protections cover:

– Protect patients from surprise bills resulting from emergency medical care. The protections apply if the patient is seen in an off-grid facility or is being treated by an off-grid clinician in a network hospital. In both cases, the patient can only be billed according to the network tariff of his package.

– Protect patients admitted to a network hospital for a scheduled procedure when an off-network clinician steps in and submits an invoice.

– Require non-network service providers to give patients 72 hours notice of their estimated charges. Patients would have to agree to receive out-of-network care to be billed by the hospital or doctor afterwards.

Before surprise billing was banned, patients usually had to take the initiative to calculate unanticipated charges themselves. In many cases, the hospital or doctor would go back and forth with the insurance company until they came to an agreement. But there was no guarantee that this would happen, and patients risked being placed in debt collection proceedings in situations over which they had no control.

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