“No surprises” legislation benefits rural residents from January 1

Imagine for a moment that you are a rural teacher returning home on a winter day.

As you navigate the icy roads, your car goes off the road and falls into a ditch. A passing motorist sees the accident and dials 9-1-1. Unconscious, you are not aware of what is going on. When the emergency medical team arrives to treat you and there is no one around to give their consent.

The small critical access hospital in your hometown, however, cannot provide you with the care you need, so you are boarded an air ambulance and airlifted to a medical center in a nearby urban area. You are accompanied by a nurse and a paramedic, who will provide you with the care you need to get you to the medical center alive. Again, you have no choice where to go. No one checks your insurance to make sure the hospital is in your network.

After you arrive at the hospital, you are treated by emergency physicians, anesthesiologists, pathologists, x-ray technicians and attending surgical staff. Within days, you recovered and were released from the hospital.

Three months later, the bills start to arrive.

The hospital may be part of the network, but the anesthesiologist is not. Although your insurance covers your hospital stay, it only pays the anesthesiologist what it would pay any other anesthesiologist. The anesthesiologist bills you for the rest. And since your insurance company does not cover air ambulance trips, you are responsible for the entire bill, which can run into the tens of thousands of dollars. Even if you have not chosen the air ambulance company or authorized to be transported that way, you are responsible for personal expenses. Since this is not covered by your private insurance company, the expense does not apply to your deductible either.

With the salary of your teachers, you are not able to foot the bill which could amount to what you earn in a year. The invoice is sent to the collections. Unable to pay, you are forced to file for bankruptcy, ruining your credit.

Scenarios like these, say the researchers, are common. But new legislation designed to tackle surprise medical bills and bills for air ambulances will come into effect on January 1, 2022.

As part of the No Surprises Act, the US Departments of Health and Human Services (HHS), Labor and Treasury, as well as the Office of Personnel Management (OPM), have issued new rules and requirements. regarding health care costs which aim to get rid of surprise billing and balance billing. The new rules also apply to services provided by ambulances and air ambulances.

Often the fastest mode of transportation for rural patients in an emergency is the air ambulance. With the closure of rural hospitals, said Melissa Ballengee Alexander, professor of law at the University of Wyoming, in her article “Inequity in rural health and the abyss of air ambulances”, Air ambulances are a necessary mode of transportation, but they add to the inequity of rural health care, increasing costs for rural residents.

“Three-quarters of air ambulance travel is off-grid, and the average balance sent to patients far exceeds the savings for most Americans,” Alexander wrote in the Wyoming Law Review.

Providers require uninsured and underinsured people to pay up to 9.5 times the rate paid by Medicare. These inequitable costs and cost transfer problems worsen each year, and they are borne disproportionately by the rural populations who can least afford them. In addition to cost and cost transfer issues, there are supply issues. In some areas, the oversupply of air ambulances has dramatically increased prices as more providers spread their high fixed costs onto fewer patients. In other areas, there are not enough air ambulances available within a reasonable response time. The problem is particularly acute in rural areas, which rely heavily on air ambulance transport to fill gaps in access to healthcare.

Patients rarely have control over how air ambulances are used when it comes to their care, as well as what services are used and whether or not they are covered by their insurance provider.

The Centers for Medicare & Medicaid Services (CMS) have estimated the median cost of air ambulance transportation to be between $ 36,000 and $ 40,000. Although air ambulance providers are not allowed to send surprise bills to Medicaid or Medicare patients, patients with private insurance often find that their air ambulance trips are off-grid, leaving them with surprise bills. of several tens of thousands of dollars, according to CMS. The share of costs passed on to patients is unclear.

A CMS spokesperson said air ambulances were something the Biden administration was including in the Law without surprise.

Passed as part of omnibus legislation to fund the federal government in 2021, as well as to provide relief funds in the event of a Covid-19 pandemic, the new rules and requirements of the No Surprises Act would protect consumers from off-grid bills and billing the balance, the spokesperson said. noted.

Currently, when an insurance plan does not cover off-grid care, the insurer can deny a patient’s bill entirely or pay only part of the bill. When this occurs, the patient is liable for the balance of the bill, which is the difference between the undiscounted charges billed by the provider and the amount reimbursed to the provider by the insurance plan.

Billing the balance can leave patients in charge for hundreds or even thousands of dollars.

Loren Adler, Associate Director of USC-Brookings Schaeffer Initiative for Health Policy, said the “no surprises” law will solve this problem.

The No Surprises Act will, for its part, completely stop the situation. If you go to an establishment in the network or the establishment in which you ended up is part of your insurer’s network, the nominal status of the network of the anesthesiologist who assists the procedure or of the radiologist who performs the imaging or pathologist reading a biopsy. It doesn’t matter whether they are off-grid or on-network, your insurance company should treat this service as if it were on-network and that means your cost sharing will be regardless of the standard level of the network. And that has to apply to the network franchise if you have that, and likewise, if you have a disbursement limit on how much you can be held liable for a year, that will also apply there. This should definitely eliminate this worry completely, and it would simply be illegal for the anesthesiologist to send you a balancing bill in this situation.

Under the new rules, in an emergency, off-grid providers would only be allowed to bill what the grid providers would charge, and they would be prohibited from billing the patient for anything that the insurance does not cover.

Over the summer, the White House announced that departments and the OPM had drafted their first set of requirements for emergency services, air ambulance services and non-emergency services provided by non-emergency providers. network in network facilities and require insurance companies and air ambulance service providers to submit information on air ambulance services.

“The air ambulance sector is a very consolidated market which often results in surprise bills for patients,” Xavier Becerra, Secretary of Health and Social Services, said in a statement.

More recently, at the end of September 2021, the ministries issued a to reign which aims to get patients out of the midst of payment disputes between healthcare providers and insurance companies. The rule also aims to provide a transparent process for settling off-grid tariffs between providers (including air ambulances) and payers.

“So (with the new rule) it would be illegal to send an off-grid air ambulance bill,” Adler said. “The insurer must treat this as a network. They must apply what the network charges would have been for an air ambulance ride. If the air ambulance carrier is unhappy or does not agree with the amount it is being paid by the insurer… it can challenge it through an arbitration process which will render a final decision.

The arbitration between insurers and providers would however take place behind the scenes and would not affect how much the patient is responsible for, he said.

The new rule would also require healthcare providers and healthcare facilities to provide uninsured patients with clear and understandable estimates of what their scheduled healthcare services would cost them.

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