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Win for Consumers: Federal and State Responses to Surprise Bills 

Have you ever been sure you picked an in-network provider for a treatment or test, but later received a surprisingly high bill? You may have experienced “surprise billing,” something that can leave patients paying unnecessarily high bills, facing debts, and fielding calls from collection agencies.  

A “surprise bill” happens when a patient has done their due diligence by picking a health care provider and hospital within their network, but learns after receiving treatment that a certain member of their health care team is out-of-network. The patient then has to pay an out-of-network price. For example, if the anesthesiologist assisting with your surgery is the only member of the team who is not covered by your network, you might get a surprise bill from your anesthesiologist. 

If you think your provider sent you a “surprise bill,” don’t pay it before appealing their decision not to cover your care. Many people assume that their insurance company has made a correct decision, accept the denial of coverage, and then try to find a way to pay their bill themselves. But, up to 60% of patients who don’t accept the denial and file an appeal, actually win and get coverage! Our new Health Insurance Appeals module offers up-to-date information and guidance for appealing denials of coverage. 

A recent win for patients in MA proves the power of patient advocacy. When South Shore Anesthesia Associates (SSAA) repeatedly tried to collect unfairly high charges for out-of-network services, patients fought these charges. In the end, the SSAA agreed to pay a $260,000 settlement and stop surprise billing practices.

Massachusetts isn’t the only state cracking down on surprise billing practices. Connecticut, Florida, Illinois, Maryland, New York, and California already provide patients with legal protection against surprise billing. California’s AB 72 has prohibited surprise billing practices since July 17, 2017. Plus, fifteen other states have partial protections against surprise billing, though typically only covering emergency services. For more information specific to your state, visit TriageCancer.org/statelaws. 

On a national level, the No Surprises Act, effective January 1, 2022, offers protections for patients who have individual or employer-sponsored health insurance, regardless of their state. The bill protects patients from being billed for the difference in cost between in- and out-of-network providers at in-network facilities. For patients concerned about the cost of care, this law is a huge benefit. 

The No Surprises Act also provides protections for patients receiving emergency services. After January 1, 2022, insurers cannot bill patients more than the median in-network rate for out-of-network emergency services. They also won’t be able to bill patients for the difference in rates between in- and out-of-network emergency services, except in certain circumstances. 

As legal protections for patients expand, advocating for yourself, your loved ones, and your patients when navigating medical care is more crucial than ever. To learn more about patient advocacy, managing medical bills, and more, visit TriageCancer.org and CancerFinances. 

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Claire Agosti
ca@triagecancer.org