The worst kind of surprise

Just about a week ago, my youngest child, Hadley, had surgery to remove her tonsils and adenoids. The day before surgery, the doctor’s office called me to collect $511.25, which was our patient responsibility. The woman from billing was taken back when I asked “Is everyone in Anthem’s network?” She even chuckled like, “Will it change anything if someone is?”

Truthfully, it probably wouldn’t have changed our mind about getting the surgery, but I certainly would have negotiated a price ahead of time if they were. I know all too well about surprise billing and wanted to make sure I’m not being charged for out-of-network services at an in-network facility.

Related: Consolidated Appropriations Act deep dive: surprise balance billing

Surprise medical bills in the mail months after a procedure takes place when an in-network doctor refers you to someone who is out-of-network. This big surprise happened to me years ago, when I gave birth to Hadley. My OB/GYN was in network, but the anesthesiologist was out-of-network and I didn’t know that until a bill arrived months later. In North Carolina, out-of-network hospital-based anesthesiologists bill customers an average of 1020% more than Medicare reimbursements for the same services. Since out of network providers have no contractual agreements with a network, there is really no limit to what they can charge.

Sometimes, these providers will purposefully be out of network to abuse the dysfunctional system currently in place. It happens all the time with specialists, anesthesiologists and lab work. While the charges may cost you a lot at the moment, it also translates to significantly higher premiums overall for a medical plan; hence the need for it to be controlled.

In the closing days of 2020, Congress finally enacted and the President signed into law the No Surprises Act. This will provide new federal protections for the consumer against surprise medical bills. For two years, there was a congressional debate over how to tackle the issue and at times, it seemed it would be dead on arrival. Ironically though, surprise medical bills are not a problem for public programs like Medicare and Medicaid, because they prohibit balance billing.

The No Surprise Act has key protections to hold consumers harmless from egregious out-of-network charges. The new law takes effect for health plan years beginning on or after January 1, 2022 and it applies to nearly all private health plans offered by employers (including grandfathered group health plans and the Federal Employees Health Benefits Program), as well as non-group health insurance policies offered through and outside of the marketplace.

Rachel Miner is the founder and owner of Thrive Benefits LLC.