Ban on “surprise” medical bills on track for January 1 rollout

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WASHINGTON – The Biden administration finalized Thursday on protecting consumers from so-called “surprise” medical bills. The ban on charges that hit insured patients at some of life’s most vulnerable times is on track to come into force on January 1, officials said.

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Patients will no longer have to worry about having a huge bill as a result of a medical crisis if the nearest hospital emergency room is outside of their plan’s provider network. assurance. They will also be protected against unforeseen costs if an out-of-network clinician participates in a surgery or procedure performed at a network hospital. In such situations, patients will only be responsible for the amount of their cost sharing in the network.

The rules released Thursday set out for the first time a key part of the new system: a behind-the-scenes dispute resolution process that hospitals, doctors and insurers will use to haggle over fees, without dragging patients into it.

When an insurer and a service provider disagree on a fair payment, either party can initiate a 30-day negotiation process. If they still can’t come to an agreement, they can take the matter to an independent arbitrator.

The arbitrator will use a fixed amount as a guide intended to balance the value of the medical services provided in an effort to keep costs from skyrocketing out of control. Clear justification will be required for the final payment to be higher or lower.

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There will also be a new way for uninsured people and self-paying patients to get a cost estimate for medical procedures, as well as a process for them to resolve billing disputes.

“We hope to give a sigh of relief to people who have been caught off guard by the billing,” said Xavier Becerra, Secretary of Health and Social Services.

Surprise medical bills have been a common problem for people with health insurance, all the more irritating since most patients would have thought they were protected. Fees ranging from hundreds to tens of thousands of dollars came from doctors and hospitals outside the patient health insurance plan network. It is estimated that around 1 in 5 emergency room visits and 1 in 6 hospitalizations triggered a surprise bill.

Related: 1 visit to the emergency room or hospital stay in 6 triggers a “surprise” bill

Although many states have already limited surprise billing, federal action was needed to protect patients covered by large employer plans, which are regulated nationally. A 2020 law signed by then-President Donald Trump set out a bipartisan strategy to address the issue, and the Biden administration provided critical details.

The idea was to take patients and their families out of the financial equation by limiting what they can be billed for off-grid services to fees based on network fees. This amount is included in their annual deductible in the network.

The new protections of the law aim to:

– Protect patients from surprise bills resulting from emergency medical care. The protections apply if the patient is seen in an off-grid facility or is being treated by an off-grid clinician in a network hospital. In both cases, the patient can only be billed according to the network tariff of his package.

– Protect patients admitted to a network hospital for a scheduled procedure when an off-network clinician steps in and submits an invoice.

– Require non-network service providers to give patients 72 hours notice of their estimated charges. Patients would have to agree to receive out-of-network care to be billed by the hospital or doctor afterwards.

– Prohibit air ambulance services from sending patients surprise bills greater than the amount of cost sharing in the network.

Before surprise billing was banned, patients usually had to take the initiative to calculate unanticipated charges themselves. In many cases, the hospital or doctor would go back and forth with the insurance company until they came to an agreement. But there was no guarantee that this would happen, and patients risked being placed in debt collection proceedings in situations over which they had no control.

Some groups in the healthcare industry have urged the Biden administration to take more time to put the new arbitration system in place. Officials said Thursday they remain committed to the January 1 effective date and said 50 organizations have expressed interest in taking on the role of arbiter.

By RICARDO ALONSO-ZALDIVAR, Associated Press.


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