Ban on ‘Surprise Billing’ in Health Plans a Work in Progress, Analysis Says – FEDweek

The ban on “surprise billing” in health insurance programs—including the federal employee/retiree FEHB program—that took effect at the start of this year is not an absolute one and its implementation is still a work in progress, according to the Kaiser Family Foundation.

The foundation, which produces reports and recommendations on health insurance issues—and which is not associated with the Kaiser health-care provider—said the change in law “creates important new protections” against being hit with unexpected charges for unknowingly getting care from providers outside of their plan’s network.

Such billing can occur, for example, in emergency and other urgent care settings when enrollees don’t have time to check whether facilities are in-network, or when they receive care at an in-network facility from providers who are out of network. The foundation had found in a 2019 survey 39 percent of respondents had received an unexpected medical bill in the prior 12 months, 13 percent of those for $2,000 or more.

The 2020 No Surprises Act, passed with bipartisan support, bans surprise billing for emergency services, bans high out-of-network cost-sharing for emergency and non-emergency services, bans out-of-network charges for ancillary care (such as for anesthesiologist or assistant surgeon) at an in-network facility, and bans other out-of-network charges without advance notice.

“The law is highly complex, however, setting coverage and billing standards for a specific subset of private insurance claims that could number 10 million annually. Providers are permitted to ask consumers to waive their NSA protections in some cases,” the analysis said.

While audits of health carriers will provide some oversight of their compliance, that will involve various federal and state entities and “it remains to be seen how these new systems will work, independently and in coordination.”

“To a large extent, oversight and enforcement will rely on complaints. In order to complain, though, consumers will need to understand that they should not be overbilled for emergency services or for non-emergency out-of-network services while they are in in-network hospitals and facilities,” it said.

“Finally, it remains to be seen if any other tools will be employed to monitor trends in the incidence of surprise medical bills, and how effectively the law may work to protect consumers from surprise bills and reduce their out-of-pocket costs,” it said.