By Fred Clasen-Kelly
Read more at: Kaiser Health News
Using 2019 data from the IRS, researchers found that out of 275 hospital systems across the country, 227 spent less on community investments or charity care than they got in tax breaks. The deficit totaled more than $18 billion, the report said.
Leah Kane is a senior attorney for consumer protection at Charlotte Center for Legal Advocacy, a nonprofit that provides civil legal assistance to people who cannot afford an attorney. She said her agency receives calls from people who were not offered charity care from hospitals.
She said her group is worried that hospitals are offering charity care to uninsured patients but not to other people, like the underinsured, who don’t have the income to pay thousands of dollars for treatment not covered by their insurance plans.
“People are angry and stressed out,” Kane said. “They don’t know what this [debt] will mean for their lives.”Hospitals Said They Lost Money on Medicare Patients. Some Made Millions, a State Report Finds. | Kaiser Health News (khn.org)
The No Surprises Act protects people from “surprise medical bills.” These protections apply to anyone enrolled in a private health insurance plan, including employer plans or a plan purchased on or off the marketplace. New protections were added in 2022 to restrict excessive out-of-pocket costs from emergency and non-emergency services. If you’re uninsured or you decide not to use your health insurance, these protections allow you to get a good faith estimate of the cost of your care up front, before your visit. If you disagree with your bill, you may be able to dispute the charges.
Even though surprise bills are now banned in many circumstances, enrollees should monitor their medical bills because they might need to take action to protect their rights. Note: Most of the law’s protections only apply to people with private insurance, and not to people who are uninsured or enrolled in Medicaid, CHIP, or Medicare.
New protections for insured patients
The new law protects insured people in two major ways:
- For emergency care: An insured person can get care at any emergency department, even if the care is out of network. The out-of-network emergency facility, and the doctors and other providers who treat the patient, cannot bill the patient for more than in-network cost-sharing amounts (i.e., deductible, copay, coinsurance). The plan also must apply only in-network cost-sharing.
- For non-emergency care: If the insured person goes to an in-network facility, they cannot be billed for more than the in-network cost-sharing amount for their services, even if they receive care from an out-of-network provider.
Note: Out-of-network ambulance services are not covered by the No Surprises Act and can still lead to high bills.
- In-network providers: Facilities and doctors who contract to accept a payment rate with your insurer. In-network care generally costs less than care that is out-of-network. You might still have to meet a deductible before your insurance pays the bill, or you might owe a copayment or coinsurance, depending on the type of service and your health plan.
- Out-of-network providers: Providers who do not contract with your insurer and instead charge you separately for their services. Unlike in-network providers, out-of-network providers set their own charges. Your health plan might cover some of the cost but often covers none of the cost of out-of-network services.
- Surprise medical bill: An out-of-network medical bill a person receives from an out-of-network provider for emergency services, or for non-emergency care while at an in-network facility.
Frequently Asked Questions
What is a surprise medical bill?
Generally, people enrolled in private insurance are responsible for checking their plan’s network before getting health services to ensure that the medical provider they’ve selected is in-network. In most situations, people who get medical services from an out-of-network provider are responsible for paying the out-of-network medical bills they receive. Most plans pay less for out-of-network care than they would pay for in-network care, and some don’t cover out-of-network bills at all, leaving the enrollee responsible for paying most or all the out-of-network bill.
There are some situations where a person doesn’t get to choose their medical provider and ends up receiving out-of-network care. This can happen in medical emergencies when people are taken to the closest ER. It can also happen when people select an in-network hospital for scheduled care but receive care from an out-of-network doctor they did not get to pick (such as the anesthesiologist). These scenarios are common. An out-of-network medical bill a person receives after getting care from an out-of-network provider they didn’t get to choose is known as a surprise medical bill.
What are the new protections if I don’t have health insurance or choose not to use it?
If you don’t have insurance or choose not to use it, these new rules make sure you get a “good faith estimate” of how much your care will cost, before you get care. They also allow you to file a dispute if you are charged more than $400 above the estimate.
What out-of-network providers and services must follow the new law?
Any health care provider in any emergency department or at the insured person’s in-network facility must follow the new law. A “provider” is defined broadly to include doctors, radiologists, therapists, and others. Services like imaging and lab work, preoperative and postoperative services, telemedicine, and equipment and devices are also covered. “Facilities” are hospitals, hospital outpatient departments, and ambulatory surgery centers. They don’t include other settings, such as urgent care.
What should I do if I receive a surprise medical bill?
The first step is to check with the insurance company to see if the provider made a mistake. The out-of-network provider shouldn’t bill for more than the in-network cost-sharing amount for the service(s) indicated on the Explanation of Benefits (EOB). If there is no EOB it might mean that the provider didn’t contact the insurance company as required.
The second step is to contact the out-of-network provider and ask them to correct the bill. Providers can face fines up to $10,000 per violation for not following the new rules.
If the provider refuses to resolve the issue by correcting the bill, then it might be necessary to file a complaint by calling the No Surprises Help Desk at 1-800-985-3059. The No Surprises Help Desk is also available for people who have questions or want more information about the new rules. Consumers can also file complaints online at www.cms.gov/nosurprises.
A mistake made by a person’s insurance company could also result in a surprise medical bill. If that happens, the person should call their insurance company, explain the situation, and ask them to treat the claim as a surprise medical bill. If the insurance company doesn’t correct the issue, the next step is to file an appeal with the insurance company. If this is unsuccessful, the next step is to request an external appeal.
Note: Every EOB a person receives is required to include instructions for how to file an appeal.
In North Carolina, the Consumer Services Division of the Department of Insurance can help people file appeals and resolve billing and coverage problems, including surprise medical bills.
What out-of-network providers and services are not covered by the new law?
Services that are scheduled in advance directly with an out-of-network provider are not covered under the new law, and the provider can charge patients the full cost for services.
Are all high medical bills considered surprise bills?
Cost-sharing charges can vary widely across insurance plans, which means that a person could still receive very high medical bills due to their plan’s standard in-network cost-sharing charges being high. These kinds of bills are not considered surprise medical bills.
No Surprises Act, Centers for Medicare and Medicaid Services (CMS)
Overview of rules & fact sheets | CMS
Consumers: new protections against surprise medical bills |CMS
Medical bills can be confusing, overwhelming, and often come when you are already in distress. It can be difficult to understand what you owe, to whom, and by when. It can also seem that you are being pushed to pay amounts you cannot afford or do not owe to protect your credit. If this sounds like you or a loved one, there is help available.
Here’s what you need to know:
- Under the Affordable Care Act, nonprofit hospitals (like Atrium CMC and Novant Presbyterian) are required to offer financial help to certain people who cannot afford their medical care. Financial assistance is an important part of the nonprofit hospital’s commitment to its community.
- Ask for a copy of the Financial Assistance policy and Application up front. Fill it out as soon as possible and provide all required information.
- Getting help with medical bills does not jeopardize your immigration status. If you are not a citizen, you can ask for and receive help with medical bills for you and your family, without fear of negative consequences to your immigration status. If you speak a language other than English, you can ask for the information in your preferred language.
- Even if your bill is past due and you’re being contacted by a debt collector, you can ask the debt collector to pause collections while you seek financial help through the hospital’s program.
- In North Carolina, most past due medical debt cannot be garnished from wages, even after a lawsuit. (This will vary by case.) Contact the hospital or medical provider to ask for assistance up front.
- If you’re having an issue with debt collection, you can submit a complaint with the CFPB online or by calling (855) 411-CFPB (2372). The Consumer Financial Protection Bureau (CFPB) takes complaints over the phone in Spanish and 180 other languages at 855-411-CFPB (2372).
How to ask about financial assistance or charity care for medical bills:
- Ask for a copy of the hospital’s Financial Assistance Policy up front. By law, the policy must explain how to apply for help.
- Fill out an application form, if required, and be ready to provide information about your income, including last year’s tax forms or a current pay stub, and your expenses, including your rent or mortgage payment, utilities, credit cards, and other debts.
- Ask your provider how long it takes to process your application for financial assistance, how to get answers to questions about the application, and what happens with your bill in the meantime.
- Notify any debt collectors that you’re seeking financial assistance for the bill and tell them to pause collections while that process plays out—and if they already reported it on your credit, to show the bill as disputed.
- Follow up with your provider about the status of your application as necessary.
Are you getting the help with your medical bills you are entitled to?
Your rights when dealing with debt collectors
Know your rights and protections when it comes to medical bills and collections
Submit a complaint to the Consumer Financial Protection Bureau