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No Suprises Act Stops Balance Billing From Out-of-Network Providers of Emergency Care

Stethoscope on medical bills and health insurance claim form

Say you go to a doctor or hospital that you know is in your insurance network. You pay your deductible and/or co-pay and expect the rest will be covered by insurance. Weeks or months later, you get an unexpected bill in the mail. While the office or facility you visited was in-network, one or more of the providers you saw was out of network, even though they operated out of the covered facility. If you have a PPO, your insurance only covered a small fraction of that out-of-network provider’s bill, or they applied the bill to a separate out-of-network deductible you haven’t met yet. If you are on an HMO, including a Medi-Cal plan like Anthem Blue Cross, Health Net or Blue Shield Promise, your insurance company denied coverage of that out-of-network service altogether.

Whether your insurance covers some of that bill or none of it, the balance gets billed to you. That’s a practice known in the industry as balance billing, but to consumers who had no idea they’d be getting a bill, it’s known more commonly and colorfully called surprise billing. A recent federal law was enacted to stop this practice, but that doesn’t mean it isn’t still happening. Read about the No Surprises Act below and how it handles balance billing. If you’ve been the victim of unfair, unreasonable or bad faith insurance practices, contact Gianelli & Morris to speak with an experienced and dedicated California insurance law attorney.

What Is the No Surprises Act?

The No Surprises Act, included in Congressional appropriations for 2021, was signed into law on December 27, 2020, and went into effect starting January 1, 2022. Several government agencies, including the Departments of Labor, Treasury, and Health and Human Services, were tasked with drawing up regulations and guidelines to implement the new law. That process is still ongoing.

At its core, the No Surprises Act prohibits balance billing for emergency services. Balance billing is what is left over after you’ve paid your deductible and copay and your insurance company has paid their share; anything left over gets billed directly to you. Balance billing is generally legal in most instances when you go to a provider that does not have a business relationship with your insurer or where you opt for services that are not covered by your health plan, even if you are using a contracted provider. With the No Surprises Act, however, balance billing for emergency services is henceforth illegal, with the exception of charges for ambulance ground transportation.

Instead of balance billing, the No Surprises Act limits your out-of-pocket liability to the in-network amount in the following situations:

  1. Emergency medical care provided by out-of-network facilities and providers. When seeking medical care outside of an emergency situation, you have the time to choose a doctor or facility that you can be sure is in your network. When you have an emergency, however, you’ll go to the nearest hospital you can find, and it’s not fair or even safe to require you to take the time to locate an in-network emergency department.

  2. Care delivered at an in-network facility by an out-of-network provider. Even if you go to a hospital you know to be in-network, that doesn’t necessarily mean the physician, surgeon, anesthesiologist, pathologist or other provider involved in your case is in that same network. That’s why you can end up with a pile of bills from multiple providers for thousands of dollars without any help from your insurance company.

Call Gianelli & Morris to Fight Bad Faith Insurance Practices in California

Before the No Surprise Act, 20% of people who visited the ER later received a surprise medical bill. Even when the hospital they went to was in their insurance network, they still received a surprise medical bill about 17% of the time. Now, hospitals must notify patients of out-of-network care and only bill for the in-network expenses.

The rules also require the creation of a complaint system to resolve disputes over surprise medical bills, which anticipates that providers and insurers might still get it wrong and bill more than they should. If you find yourself being billed more than you think is proper and can’t resolve the issue without help, call Gianelli & Morris at 213-489-1600 to speak with a California insurance law attorney. We represent California policyholders victimized by unlawful bad faith insurance practices.

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