Preventing and fighting surprise medical billing: steps consumers should take

Thirty-two percent of insured individuals who had problems paying medical bills reported receiving care from an out-of-network provider that their insurance did not cover, while 69 percent of those individuals said they were not aware that the provider was not in their plan’s network when they received the care, according to a Kaiser Family Foundation (KFF) survey published in January 2016. Betsy Imholz, special projects director and a surprise medical bill expert at Consumer Reports, noted in a January 17, 2017, article that “the problem is only growing worse as our healthcare system grows more complex and more insurance companies narrow the network of doctors they contract with or shift to insurance plans that eliminate coverage for out-of-network services.”

What is a surprise medical bill?

A medical bill that an insured individual receives from an out-of-network provider when the individual is unaware that the provider is out-of–network is referred to as a “surprise medical bill.” Out-of-network providers may charge patients whatever they choose and may bill the patient for the amounts that were not paid by the patient’s health plan, referred to as a “balance bill.”

According to a March 2017 KFF report on surprise medical bills, such bills may arise from an emergency when the individual does not have the ability to select providers. Often, emergency room (ER) physicians do not participate in the same health plan networks as the hospitals where they work. In addition, the patient may not have had the ability to choose the hospital or the ambulance provider. In situations when a patient receives planned care, such as a planned surgery from an in-network provider (for example, a hospital or ambulatory surgical center), other providers involved in the surgery may not be in the same network. In many nonemergency situations, the in-network provider rather than the patient arranges for the other providers participating in the procedure or treatment. Such providers may include anesthesiologists, radiologists, pathologists, and surgical assistants.

What consumers can do

Individuals can prevent surprise medical bills by avoiding receiving services from out-of-network providers, when possible, and fight surprise medical bills after receiving them. A Center on Health Insurance Reforms (CHIR) report identified the following steps for patients to take to prevent unexpected charges:

  • Use provider directories and other plan provided information to identify in-network providers;
  • Ask providers if they are in the patient’s health plan network;
  • After receiving a balance bill, the patient should review the plan’s explanation of benefits and notices about consumers rights;
  • Before paying a balance bill, the patient should contact the health plan and the provider to find out if the plan is willing to pay the bill and/or if the provider will accept a lesser amount; and
  • Contact the state insurance department to see if there is a remedy under  state law.

Additional tips for patients were addressed in an April 6, 2017, article in Consumer Reports written by Donna Rosato. In cases of emergency care or if ambulance service is needed, Rosato recommended the individual to ask the first responders or ER doctors to provide documentation confirming that the individual had no choice and transport by ambulance was medically necessary. She noted, however, as a preventive measure, that individuals find out, before needing to go to an ER, which nearby hospitals are in-network and which ER physicians are in-network. Then, in an emergency, if possible, the individual can request to be taken to an in-network ER. In nonemergency situations, such as a planned surgery, Rosato also suggested that individuals obtain a list from the doctor’s billing staff (and hospital) of other providers that may be part of the procedure or treatments such as an anesthesiologist, radiologist, and pathologist. Then contact the insurance plan and ask if the providers identified are in-network. If the providers are out-of-network, the individual should notify the attending physician and request providers who are in-network.

Highlight on New York: State guidance supports ACA initiatives

The New York Department of Financial Services (NYDFS) recently released guidance to ensure that insurers are following through on Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) and CMS mandates to provide preventive services recommended by the U.S. Preventive Services Task Force (USPSTF) at no charge to patients and to facilitate enrollment during special enrollment periods (SEPs). Specifically, it circulated guidance requiring issuers to provide coverage for maternal depression screening and to allow victims of domestic violence to apply for health insurance coverage, both on and off the exchange, year-round.

Maternal Depression Screening

Section 1001 of the ACA amended section 2713 of the Public Health Service Act (42 U.S.C. § 300gg-13) to require nongrandfathered health plans to provide certain preventive services, without copays, to plan recipients. The services fall into four categories, one of which covers evidence-based items or services that have in effect a rating of ‘A’ or ‘B’ in the current recommendations of the USPSTF.  In 2009, the USPSTF recommended screening all adults for depression when staff-assisted depression care supports were in place and suggested selective screening based on professional judgment and patient preferences when such supports were not in place.  Since that time, depression care supports have become more commonplace.  As a result, the task force updated its recommendations in 2016 to omit the recommendation regarding selective screening and recommend depression screening for all adults, specifically including pregnant and postpartum women; the rating carries with it a ‘B’ recommendation. The USPSTF noted that the American Academy of Pediatrics recommends postpartum depression screening at infants’ one-, two-, and four-month visits, while the American College of Obstetricians and Gynecologists recommends screening at least once during the perinatal period.

The NYDFS issued guidance to insurers on April 25, 2016, reminding them that the USPSTF granted maternal depression screening a ‘B’ rating and that they are required to covers such services pursuant to 42 U.S.C. § 300gg-13. According to Governor Cuomo’s office, issuers should begin providing coverage as soon as possible, but no later than six months from the date of the notice. Furthermore, the NYDFS noted, Chapter 199 of the Laws of 2014 (which added §§ 3217-g, 4306-f, and 4406-f), requires that insured women are entitled to direct access to screening and referral  for maternal depression treatment by an obstetrician/gynecologist (OB/GYN) or pediatrician of their choice. In addition, existing law requires that mental health services have parity in insurance coverage.

SEPs for Victims of Domestic Violence

Qualified individuals or enrollees and their dependents are eligible for special enrollment periods, pursuant to 45 C.F.R. 155.420(d)(9), if they meet specified exceptional circumstances. As of July 27, 2015, CMS opened a permanent SEP for any household members victim to domestic abuse, victims of spousal abandonment, and their dependents, for 60 days following an individual’s request for enrollment. CMS also noted that victims who are married to their abuser or abandoner and are applying for coverage separately may be eligible for advance premium tax credits (APTCs) and cost-sharing reductions (CSRs); the federally-facilitated marketplace will  allow them to indicate that they are unmarried without fear of penalty, but other marketplaces may also elect to attest to an expected filing status of Married Filing Separately.

The NYDFS notified all insurers and health maintenance organizations (HMOs) offering comprehensive health insurance coverage in the individual market that they should honor this SEP, whether they offer coverage on or off New York State of Health (NYSOH), the state exchange. The governor’s announcement noted that the SEP began April 15, 2016. Coverage for applications received through the 15th of any month will go into effect on the first day of the following month, while applications received after the 15th will be effective the first day of the second following month.  Although insurers and HMOs may request a separate statement or include an item on the application regarding eligibility, they may not require proof of eligibility or other overly burdensome requirements, nor may they require that applicants have been a victim of domestic violence or spousal abandonment with a specific timeframe.