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“I think this is so pro-consumer, it’s so pro-patient—and its effect will eventually be felt by literally everybody who interacts with a health care system,” said Senator Bill Cassidy, a Louisiana Republican who was one of the bipartisan team that got the bill passed. “This is such an important consumer victory because it is going to protect consumers from an egregious and pervasive billing practice that has just grown over the years,” said Patricia Kelmar, health care campaigns director for consumer group U.S. PIRG.
The new law won’t eliminate things like coinsurance payments and deductibles for out-of-network or emergency care, but it will mean consumers don’t have to foot the entire bill. Those payments “cannot be higher than if such services were provided by an in-network doctor, and any coinsurance or deductible must be based on in-network provider rates,” CMS has ruled. The rule
- Bans out-of-network charges for ancillary care (like an anesthesiologist or assistant surgeon) at an in-network facility in all circumstances.
- Bans other out-of-network charges without advance notice. Health care providers and facilities must provide patients with a plain-language consumer notice explaining that patient consent is required to receive care on an out-of-network basis before that provider can bill at the higher out-of-network rate.
There’s one key exception: ground ambulances. Lawmakers found negotiating that part of the bill too complicated, having “little data on the actual costs of ambulance trips, and worried about tussling with the local governments that often oversee these services—especially those whose budgets have been battered by the economic downturn.” Ambulance and EMT services are often contracted by city or county governments and are generally not included in regular network insurance plans. And it’s still a problem for consumers.
“From a policy standpoint, the omission of ground ambulances is huge,” said Karan Chhabra, a surgical resident at Brigham and Women’s Hospital and an expert on the issue. “It affects a really large number of people, even if the size of the bills isn’t eye-popping.” Whether or not it’s eye-popping is generally a question for the person having to foot the bill. Ambulance services rack up about $129 million in surprise bills every year. The law did establish a commission to gather data on the issue, and Medicare is reviewing its payment rates. That means future legislation could include these services in the surprise billing ban.
The law doesn’t mean that there’s no work involved for patients with planned medical procedures. If a patient wants to have treatment from a specific provider outside of their insurance network, they’ve got to get a “good-faith estimate” of what that charge will be from the provider three days ahead of the procedure. If that is excess of what insurance would cover, the patient might be pushed to sign a form agreeing to pay extra, but can’t be forced to by the hospital or clinic as a condition for being cared for. The form will also provide a list of providers who will accept your insurance. “People should really, really think carefully before they sign that form, because they will waive all of their protections,” Kelmar said.
For routine care, people still need to stick with the doctors in their insurance network in order to have it covered, because visits to out-of-network providers could still result in extra bills.
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