New laws to protect patients from surprise medical billing

A Maine law enacted in March 2020, An Act To Protect Consumers from Surprise Emergency Medical Bills, and a new 2021 federal law, the No Surprises Act (NSA), are meant to help patients with surprise billing. The federal law passed with strong bipartisan support.
Surprise billing is the term used for healthcare provider and facility bills that are out of a patient's provider network and are usually an unscheduled cost, thus the surprise. The federal NSA law is estimated to apply to about 10 million out of network surprise medical bills a year, according to the federal government. Surprise bills can range from a few thousand to even more significant sums, potentially causing financial hardship and even bankruptcy.
"The No Surprises Act offers significant relief to people across the country and reinforces our fundamental belief that no one should go bankrupt when seeking necessary care," says Centers for Medicare and Medicaid Services (CMS) Administrator Chiquita Brooks LaSure. "We are making it easy for consumers to know and understand their rights under the law, including what they can do if they receive a surprise medical bill. Consumers will not only benefit from these rights but also will be empowered with the knowledge to address potential violations."
The Kaiser Family Foundation (KFF) reports that surprise billing happens in about one in five emergency room visits. KFF states, "Between 9% and 16% of in network hospitalizations for non emergency care include surprise bills from out of network providers, such as anesthesiologists, whom the patient did not choose. Surprise medical bills pose financial burdens on consumers when health plans deny out of network claims or apply higher out of network cost sharing; consumers also face 'balance billing' from out of network providers that have not contracted to accept discounted payment rates from the health plan."

A frustrating dispute process
Robbinston resident Valerie Lawson could have used the NSA in 2021 when for one month she was uninsured and suffered from a medical emergency that landed her for three days at Northern Light Eastern Maine Medical Center in Bangor. When she got home she received a bill for $21,000, with $15,000 of the bill for one specialized procedure. "It was a very expensive three days," she says.
Looking over her bill, Lawson saw a charge for a $3,000 medication. It was the start of a frustrating eight month dispute process. "Medical billing issues are a gigantic rabbit hole," she says. Having had some medical billing experience in her past, she went to the state website that shows standard medical costs and found the medication for $150. There were a number of other costs that didn't make sense to her, including what looked like duplicate charging. Part of the problem, she explains, is that the healthcare facility uses internal billing codes, not standard codes, so she could not look up the codes on her bill to see what the bills were for. At one point she asked the Northern Light billing representative if there was an ombudsman she could work with and "they didn't know what that was." Hospitals have patient advocates, and eventually Lawson found that person, but not through a referral from the billing department.
Lawson was in the dispute process trying to figure it out on her own. "It took eight months to get someone on the phone to talk with me in a reasonable way about what I was being billed for. And this only happened after I complained to the [Northern Light] patient services representative, Rep. Anne Perry, Rep. Jared Golden, Maine Equal Justice Partners and the Maine Attorney General's office." Finally a person from the doctor's office reached out to Lawson. "They realized I had a serious complaint." After going through the bill with her and explaining why some charges looked like duplicates but were not, Lawson began to feel better. "If they had told me this right away it would have saved a lot of time." As it was, she did get about a 25% discount, but she still had to take out a mortgage to pay for the remaining bill.
Lawson doesn't know if the new NSA bill would have helped. "Even with protections, there isn't a lot of information about resolving issues." The Maine law was in effect, and no one ever mentioned it to her. There's plenty of information out there for those who are insured, but for the uninsured resources are much scarcer and harder to find, she adds. In addition, she points out that with emergency care it's rare that a patient is in a position to negotiate, reject or otherwise determine what kind of care they're going to receive. She adds that knowing what local healthcare facilities provide and charge for their services is important to know. When Lawson checked what the $15,000 procedure she received in Bangor would have cost elsewhere she found that the Northern Light Eastern Maine Medical Center cost was the second highest in the state.
Maine Bureau of Insurance Public Information and Consumer Outreach Specialist Judi Watters explains that the 2020 Maine law implemented an Independent Dispute Resolution (IDR) process, a protection included in the federal No Surprises Act. "IDRs can be initiated by uninsured patients, as well as persons covered in self insured plans, and by out of network healthcare providers. Insured patients aren't included in this list, because our law is clear that they are to be kept out of any payment disagreements between insurance carriers and out of network providers. Uninsured individuals may submit disputed bills that total $750 or more for emergency health services for a single visit, regardless of the number of providers."
She adds, "The federal law requires health plans to inform members of their rights under the new law, and it requires health facilities and providers to inform patients, including the uninsured, of those rights, as well."

DECH, CCH takes steps to implement the law
Of the new law, Julie Hixson, director of marketing and communications at Down East Community Hospital, and speaking for DECH and Calais Community Hospital, explains, "This helps patients that are out of their provider network from being billed over the usual and customary amounts of like kind services. This does not affect patients who are already in network at our hospitals. This also allows for good faith estimates for uninsured individuals prior to scheduled services. Good faith estimates for insured individuals have not gone into effect yet."
DECH and CCH will provide information to patients to help them understand how billing has changed. Hixson says, "There will be notices posted in the hospitals. We are anticipating making phone calls to patients before services are rendered. The only exceptions to the rule are lab services and emergency room costs because these services are unscheduled." In addition, Hixson notes that DECH and CCH work with insurance companies until all billing issues are resolved. "We do not anticipate that this will change, since this is our current practice."
Hixson says of the new law, "Our main concern is that hospital charges are not static and hard to estimate when a patient is going to receive surgery or an inpatient stay. Scheduled diagnostic testing is a bit easier, but even with lab tests, sometimes the results of a particular test may indicate that more are required that are automatically performed. Hospital services are very hard to give an exact cost for. In addition, when checking patient deductibles through the means we have available, the information provided to us is only as good as the insurance provides at that moment in time. There may be claims in transit from other organizations that may affect payment on our claim when it is actually submitted."
She adds, "This regulation makes it harder on hospitals, especially small ones that don't have the technology to closely estimate charges, to fulfill every aspect of what is requested. In addition to being paid less for certain services, it will drive up costs as each hospital will need to add another financial counselor to comply."

NSA provisions for insured, uninsured
According to the Centers for Medicare and Medicaid Services, the NSA provides the following protections for the insured. It bans surprise bills any time you receive emergency care and requires that cost sharing for these services, like co pays, always be based on in network rates, even when care is received without prior authorization. It bans surprise bills from certain out of network providers if you go to an in network hospital for a procedure. This means cost sharing for certain additional services during your visit will generally be based on in network rates. It requires providers and facilities to share with patients easy to understand notices that explain the applicable billing protections and who to contact if they have concerns that a provider or facility has violated the new surprise billing protections.
For the uninsured, the NSA provides the following protections. It requires most providers to give a "good faith estimate" of costs before providing non emergency care. The good faith estimate must include expected charges for the primary item or service, as well as any other items or services that would reasonably be expected. For an uninsured or self pay consumer getting surgery, for example, the estimate would include the cost of the surgery, as well as any labs, other tests and anesthesia that might be used during the procedure. Uninsured or self pay consumers who receive a final bill that exceeds the good faith estimate by $400 or more can dispute the final charges.
For more information about the No Surprises Act, visit the Centers for Medicare and Medicaid website at www.cms.gov/nosurprises.
A toll-free number for the federal No Surprises Help Desk is being developed at 1 800 985 3059.
For more information about the Maine Bureau of Insurance IDR process, visit www.maine.gov/pfr/insurance/consumer/employers_other_groups/health/independent_dispute_resolution/index.html.