It’s not difficult to imagine the dismay many patients have felt over the years, upon receiving a medical bill that exceeds expected costs by hundreds or thousands of dollars. Fortunately, surprise medical billing appears to be soon relegated to the past. In December 2020, Congress included direction within the coronavirus relief legislation and year-end spending bills to end this unpopular practice.

For example, in the event that a patient goes to a hospital normally covered under their health insurance policy, they cannot be surprise billed for services via an uncovered provider within that system. Insurance companies are now required to cover those bills. However, insurers and medical providers might still disagree over costs, in which case the bill sets forth a clear procedure to deal with those situations. This measure shifts responsibility for negotiations from the patient to the insurance company.

The new law requires parties to negotiate and agree upon a rate or bring the dispute to mediation. After batching together billing disputes, mediators will consider factors such as median in-network rates, the complexity of the medical case in question and relative market power of insurers versus doctors or hospitals.

Larger bills for out-of-network care are not outlawed entirely. If patients are informed that their insurance company will not cover the bill and notice of charges is provided at least 72 hours before onset of care, providers might still bill patients for the difference in what insurance companies would otherwise pay.

While imperfect, the new bipartisan law is expected to drastically reduce incidences of surprise billing and clarify procedures for patients, insurance companies, and healthcare providers. For more information on health insurance coverage and avoiding surprise billing, give us a call to discuss your concerns in more detail.