Surprise billing & protecting consumers
Starting January 1, 2022, consumers will have new billing protections when getting emergency care, non-emergency care from out-of-network providers at in-network facilities, and air ambulance services from out-of-network providers. “Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Through new rules aimed to protect consumers, excessive out-of-pocket costs will be restricted, and emergency services must continue to be covered without any prior authorization, and regardless of whether or not a provider or facility is in-network. The No Surprises Act (NSA) established federal protections against surprise medical bills.
Prior to January 2022, if consumers have health coverage and get care from an out-of-network provider, their health plan usually wouldn’t cover the entire out-of-network cost. This could leave them with higher costs than if they’d been seen by an in-network provider. This is especially common in an emergency situation, where consumers might not be able to choose the provider. Even if a consumer goes to an in-network hospital, they might get care from out-of-network providers at that facility.
In many cases, the out-of-network provider could bill consumers for the difference between the charges the provider bills, and the amount paid by the consumer’s health plan. This is known as balance billing. An unexpected balance bill is called a “surprise bill”.
The Consolidated Appropriations Act of 2021 was enacted on December 27, 2020 and contains many provisions to help protect consumers from surprise bills starting in 2022, including the No Surprises Act (NSA) under title I and Transparency under title II.
If patients give prior written consent to waive their rights under the NSA, they can be billed more for out of network providers. Consent must be voluntary and cannot be coerced. Providers can refuse care if consent is denied.
Federal regulations provide a standard waiver consent form, that must include key information including:
- a statement that the patient is not required to waive protections, and can try to find an in-network provider/facility instead (for post stabilization care, the notice must indicate the name of available in-network providers)
- a statement that the out-of-network provider/facility can refuse to treat if the patient refuses to waive surprise billing protections
- a statement that waiving protections could cost the patient more money in out-of-network charges
- a description of the out-of-network services to be provided, along with billing codes and a good faith (nonbinding) estimate of costs the patient may owe
The law requires that consent must be given at least 72-hours in advance or, if the patient schedules a service less than 72-hours in advance, no later than the day the appointment is made. For same-day scheduled services, regulations permit consent to be given at least 3 hours in advance. It is possible, for example, that an out-of-network doctor could ask an already-hospitalized patient in the morning to waive her NSA protections for a service the doctor schedules to be given later that afternoon.
Notice and consent are not permitted for the following:
-unforeseen urgent medical needs arising when non-emergent care is furnished
-ancillary services, including items and services related to emergency medicine, anesthesiology, pathology, radiology and neonatology
-items and services provided by assistant surgeons, hospitalists and intensivists
-diagnostic services including radiology and lab services
-items and services provided by an out of network provider if there is not another in-network provider who can provide the service at that facility
These requirements don’t apply to people with coverage through programs like Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care, or TRICARE. These programs have other protections against high medical bills.
For State of Illinois specific rights, see IL Public Act 096-1523.
If you believe you have been wrongly billed, you may contact
SIHF Healthcare at (618) 332-2081 or contact
State of Illinois Department of Insurance
320 W. Washington Street
Springfield, IL 62767
The federal phone number for information and complaints is 1-800-985-3059