Are out of network/balance billing going away in 2022?

[Fermion]

I sort of missed this part of the covid relief bill but it sure seems like the problem of getting bankrupted by an accident when you are thousands of miles from your private healthcare network is being solved?

Anyone have more info on this?

It sure would free up traveling for early retirees who are not on medicare yet.

 

[ncbill]

I sort of missed this part of the covid relief bill but it sure seems like the problem of getting bankrupted by an accident when you are thousands of miles from your private healthcare network is being solved?

Anyone have more info on this?

It sure would free up traveling for early retirees who are not on medicare yet.

https://www.jdsupra.com/legalnews/no-surprise-act-the-long-anticipated-5085731/

 

[Smitty700]

https://www.jdsupra.com/legalnews/no-surprise-act-the-long-anticipated-5085731/

This "No Surprises Act" is good news, but it doesn't take effect until January 1, 2022. The old rules apply for the rest of this year.

 

[MichaelB]

Here’s a summary from Kaiser Health Foundation https://www.kff.org/private-insuran...rotections-for-consumers-take-effect-in-2022/

From their article:

-Health plans must cover surprise bills at in-network rates.
-Balance billing is prohibited
-Out-of-network providers cannot send patients bills for excess charges.
-Specific oversight and enforcement activities are required.
-Resolving Payment Amount for Surprise Bills
-Health plans must provide an advanced explanation of benefits.
-Health plans must provide transitional continuity of coverage when a provider leaves the network.
-Health plans must maintain accurate provider network directories
-Health plans must disclose information about broker commissions

I think the only charges not covered are ambulance.

 

[Markola]

https://www.jdsupra.com/legalnews/no-surprise-act-the-long-anticipated-5085731/

Sounds like Mississippi has the most forthright solution to this unfair problem:

“Mississippi has also enacted legislation effectively outlawing certain balance billing practices. Miss. Code Ann. § 83-9-5(1)(i) provides that if the patient assigns payment of any health insurance benefits to a provider through a written direction, any payments made by the health insurance company to the provider must be considered payment in full to the provider, and the provider may not bill or collect from the patient any amount above the insurance payment, other than the patient’s applicable deductible, coinsurance, copayment or other charges for non-covered services.”

 

[Texas Proud]

Here’s a summary from Kaiser Health Foundation https://www.kff.org/private-insuran...rotections-for-consumers-take-effect-in-2022/

From their article:

-Health plans must cover surprise bills at in-network rates.
-Balance billing is prohibited
-Out-of-network providers cannot send patients bills for excess charges.
-Specific oversight and enforcement activities are required.
-Resolving Payment Amount for Surprise Bills
-Health plans must provide an advanced explanation of benefits.
-Health plans must provide transitional continuity of coverage when a provider leaves the network.
-Health plans must maintain accurate provider network directories
-Health plans must disclose information about broker commissions

I think the only charges not covered are ambulance.

Wow... nice...


I hope they do keep the network info up to date... a few years back we changed insurance and picked a PCP... and then found out that she had moved to NY a year before we chose her!!!



Looking for a specialist I called 10 of them and 8 said they did not accept the insurance...


It never got any better...


BTW, the one that had moved was still on their system the sign up time for the following year...

 

[EastWest Gal]

Don't trust the online network information. Call the practice, make sure the doctor you want is there. Call both the insurance company and the providers before you select a plan. Don't trust the info on the internet.

 

[MichaelB]

Don't trust the online network information. Call the practice, make sure the doctor you want is there. Call both the insurance company and the providers before you select a plan. Don't trust the info on the internet.

The new regulation, as explained by KFF, seems to deal with this problem. Nonetheless, I agree with EW Gal. To quote Pres. Reagan, Doveryai, no proveryai. Trust but verify.

establish a verification process to update provider directory information at least every 90 days. They also must respond within 1 business day to requests from individuals about whether a provider or facility is in-network. This information becomes binding. Consumers who rely on incorrect information conveyed by plans or posted in directories are entitled to have services covered with in-network cost sharing applied. Providers and facilities are also required to provide timely updates to health plans when the content of their directory information changes.

 

[EastWest Gal]

BTW, the "No Surprises Act" is not part of COVID relief; it was passed and signed in late 2020. It has been debated for a couple of years. It is permanent, not temporary (well at least as permanent as any legislation without an expiration date).

When I learned about this, I looked up one of our largest hospital systems. It turns out they publicly published their fees for every service code recently, which is a great start.

 

[Bongleur]

So this seems to negate the limitations of "in-network" completely, if I can choose whomever I desire.

Or are there conditions that define it as only applying to "emergency" treatment?

If a network provider cannot see me within 7 days, is that an emergency? It is as far as I'm concerned...

 

[pb4uski]

No, it only covers limited out of network bills...

Surprise bills arise in in emergencies – when patients typically have little or no say in where they receive care. They also arise in non-emergencies when patients at in-network hospitals or other facilities receive care from ancillary providers (such as anesthesiologists) who are not in-network and whom the patient did not choose.

So emergencies and also where you pick an in-network doc and in-network hospital for a surgery or treatment but the bring out-of-network providers into your care.... now you are only responsible for what you would have paid an in-network provider for those services and I assum the out-of-network provider has to accept the insurer's negotiated rate for that service with its in-network providers.

 

[daylatedollarshort]

California passed a law about out of network charge at in network hospitals a few years ago. Before the law we had surprise bills from a surgery by people we'd never seen or nor heard of until we got the bill. Post law, one of my relatives got an insurance statement rejecting the part of the bill from an out of network doctor at an in network hospital, and that was the end of it. He never sent a bill for the balance to the patient, though he did try to get the insurance company to pay it.

Nice to hear there are better laws coming nationwide on this front.

 

[EastWest Gal]

Emergencies were always supposed to be covered as if you were in-network.

 

[Texas Proud]

No, it only covers limited out of network bills...



So emergencies and also where you pick an in-network doc and in-network hospital for a surgery or treatment but the bring out-of-network providers into your care.... now you are only responsible for what you would have paid an in-network provider for those services and I assum the out-of-network provider has to accept the insurer's negotiated rate for that service with its in-network providers.

OK, here is my question on this....


Does you insurance have to pay for an out of network Dr? IOW, my insurance says they pay nothing to anybody out of network, not even the agreed upon price to in network people...

 

[zinger1457]

OK, here is my question on this....

Does you insurance have to pay for an out of network Dr? IOW, my insurance says they pay nothing to anybody out of network, not even the agreed upon price to in network people...

Starting in 2022 they will have to if it's an emergency or in non-emergency situations where in network hospitals/facilities are used but a provider you did not choose is used and that provider is out of network. I'm sure it won't be a smooth transition.

 

[audreyh1]

OK, here is my question on this....


Does you insurance have to pay for an out of network Dr? IOW, my insurance says they pay nothing to anybody out of network, not even the agreed upon price to in network people...

In the case where you had no choice in an emergency or in a procedure at an in-network hospital I believe your insurance would pay them the in-network rate and you couldn’t be billed for any extra.

Otherwise if you deliberately picked an out of network provider, they wouldn’t have to pay.

 

[Texas Proud]

Thanks for the reply... it will be for all the problems I have had so far...


I will almost always make sure to use in network, even in emergency close to home as I find out which are in network....


Adding... so, it now is up to the Dr to determine if he wants to work on you if he is not in your network... instead of you getting the surprise that he/she is not covered...