SALEM, Ore. (KTVZ) – The situation happens too often: You go to a network hospital, but receive a surprise medical bill from an off-network doctor. However, effective January 1, a new federal law – the No Surprises Act – will protect consumers from many types of these surprise bills.
Surprise billing occurs when you receive an unexpected bill after receiving care from an off-grid provider or in an off-grid facility, such as a hospital. It can happen for both emergency and non-urgent care. Typically, patients are unaware that the provider or facility is off-grid until they receive the bill.
Surprise medical bills are usually sent by your healthcare provider for the remaining charges for services you received that are not covered by your insurance (called balance billing). The new law protects consumers from any of the following situations:
- Emergency services provided off-grid, including air ambulance services (but not ground ambulance services)
- Non-urgent services provided by an off-grid provider in a network facility
In an emergency situation, a facility or provider may not charge you more than your network coinsurance, co-payments, or deductibles for emergency services as outlined in your plan documents, even if the establishment or supplier is off-grid. However, if your health plan requires you to pay coinsurance, copayments, or deductibles for networked care, you are still responsible.
In a non-emergency situation, non-network providers (such as an anesthesiologist) may not charge you more than your coinsurance, co-payment, or in-network deductibles for covered services provided at a network facility without your consent.
If you believe you received a surprise medical bill from a healthcare provider who meets any of the above criteria, contact the US Department of Health and Human Services to file a complaint by calling 800-985 -3059 (free number) or by going to https://www.cms.gov/nosurprises/consumers.
If you’ve received a surprise bill that you believe is prohibited under the new law, you can appeal to your insurance company and then request an external review of the company’s decision after the initial appeal is completed with your. diet. You can also contact the Oregon Division of Financial Regulation to speak with a consumer advocate or file a complaint in any of the following ways:
The law applies to most health insurance plans, including those offered by an employer. It includes group health plans, health insurance companies for group and individual health coverage, grandfathered health plans, ERISA plans, and government self-insured plans. Medicare and Medicaid have their own protections against balance billing.
The law also provides the following protections:
- Health plans and their institutions / providers should send you notice of your rights under the law.
- Insurance companies must keep their supplier directories up to date. They should limit co-payments, coinsurance, or deductibles to network amounts if you are relying on inaccurate information in a supplier directory.
- Healthcare providers should provide a good faith estimate for services to anyone who is uninsured or who pays for themselves (without insurance).
The Financial Regulation Division is hosting No Surprises Act: Provider Requirements, a Zoom webinar, on Wednesday, January 5, from noon to 1:00 p.m. PST. In the webinar, staff from the Centers for Medicare and Medicaid Services will outline provider requirements and answer questions from stakeholders. To view the webinar, go to https://www.zoomgov.com/j/1603031760.
More information on the new law is available at dfr.oregon.gov.
The Financial Regulation Division is part of the Department of Consumer and Business Services, Oregon’s largest business regulatory and consumer protection agency. Visit dfr.oregon.gov and dcbs.oregon.gov.