The effects of surprise billingSurprise billing happens when people unknowingly get care from providers that are outside of their health plan’s network, which can happen for both emergency and non-emergency care. Examples of surprise billing include:
- Someone breaks their leg in a fall and has to go to the nearest emergency room, which is not part of their insurer’s network. They are billed at market rates as their insurer doesn’t cover the service.
- Someone has an operation in a network hospital but one of the providers treating them (an anesthesiologist or radiologist, for example) is not in the network, so the covered individual is billed at market rates.
What the regulations doThe new regulations:
- Ban surprise billing for emergency services, regardless of where they are provided. That means if a person has no choice but to go to an emergency room that is out of network, they can only be billed at the same rate they would be charged for services at an in-network hospital.
- Bar health insurers from requiring prior authorization for emergency services, and they can’t charge their higher out-of-pocket costs for emergency services delivered by an out-of-network provider. They would also be required to count enrollees’ cost-sharing for those emergency services toward their deductible and out-of-pocket maximums.
- Ban out-of-network charges for ancillary care at an in-network facility in all circumstances. This happens when there is an out-of-network provider working at an in-network hospital.
- Ban other out-of-network charges without advance notice.
- Require providers and hospitals to give patients 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.