Editorial: No cure-all, but medical bill curb helps – Lowell Sun

Physicians do their best to prevent patients from experiencing symptoms of shock during a medical procedure.

But that can’t prevent the sticker shock that accompanies unexpected — often exorbitant – medical bills.

Patients worried about getting hit with unexpected bills after emergency care gained some measure of protection this month from a new federal law.

The No Surprises Act prevents doctors or hospitals in many situations from charging insured patients higher rates because care providers aren’t within their insurance company’s coverage network.

The law won’t eliminate all billing surprises, but it should ease some concerns, especially in emergencies where patients didn’t have time to choose an in-network doctor.

The new law ends these billing surprises for most emergency care by essentially requiring that patients receive in-network coverage with no additional billing from the provider.

It also offers protection for nonemergency care for people treated at in-network hospitals by a provider outside their network.

That can include radiology, lab work or care from an anesthesiologist.

Many states already regulate surprise medical bills. The federal law supplements those measures.

In Massachusetts, Gov. Charlie Baker signed comprehensive health care legislation on the first day of 2021 that among other measures, took steps to protect consumers from surprise medical bills.

The new legislation included a provision that requires insurance providers to notify patients in advance if a procedure is in or out-of-network.

It also directed the Secretary of the Executive Office of Health and Human Services to work with the Health Policy Commission, Center for Health Information and Analytics, and Division of Insurance to recommend a default rate for out-of-network billing by September 2021.

Sticking to that deadline, the recommendation reached was to set the default reimbursement at the in-network median contracted rate.

This decision hopefully removed Massachusetts consumers from the middle of any dispute between a health-care provider and insurer.

The federal No Surprises Act also strengthens protections against insurer claim rejections for emergency visits.

Emergency departments are expensive health-care options; insurers have been trying to limit their use to only life-threatening situations.

They’ve denied coverage if patient visits aren’t deemed to be emergencies.

Regulations in the new law note that insurers cannot deny a claim solely based on a doctor’s diagnosis. They also must consider the symptoms patients had when they arrived at the ER.

That means insurers shouldn’t deny a claim for someone rushed to the ER with heart-attack symptoms that turned out to be heartburn instead.

But these protections don’t cover every situation.

People who don’t understand what their insurance covers could be in for some unpleasant surprises.

Insurance shoppers often focus on the cost of coverage without taking into account out-of-pocket expenses like deductibles. A high deductible can lead to a bill of several thousand dollars.

This federal law requires that care providers give patients notice of the appropriate party to contact if they have concerns about a bill.

Karen Pollitz, a senior fellow at the Kaiser Family Foundation, recommends comparing any bill with an insurer’s explanation of benefits.

Knowledge is power, no more so than when trying to make sense out of byzantine health-insurance plans.

Federal and state protections have limits.

That’s why being an informed insurance consumer is at a premium.