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Loopholes in No Surprises Act can leave some patients with high bills
Some patients are still getting unexpected medical bills due to loopholes in the No Surprises Act.
HOUSTON - No Surprises Acts are now in place, both nationally and in Texas, to protect patients from getting unexpected bills for emergency health care. However, some patients are still getting high bills due to loopholes in the laws.
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Both Texas and the national No Surprises Act ban balance bills from out-of-network providers in emergencies, such as an anesthesiologist that doesn't accept your insurance.
"On my way to the hospital, I called them to ask if they accepted my insurance. They did," said Kristina Olaussen.
But after an emergency appendectomy last year, Olaussen says she received a $26,000 bill from a physician's assistant that was not in her insurance network.
"I was just shocked. Immediately I thought, this was an emergency surgery! Why can you bill me as an out-of-network provider for the full cost?" said Olaussen.
She was caught in a loophole. The Texas No Surprises Act did not originally include out-of-state insurers, such as her policy with Anthem Blue Cross in California, allowing out-of-network providers to balance bill.
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She says it took months of phone calls to get the provider to reduce the bill.
The National No Surprises Act took effect January 1, protecting patients nationwide.
"It takes them out of the middle of fights between insurance companies and providers and helps to avoid surprise bills when they don’t have control over the provider," said Alicia Pierce with the Texas Association of Health Plans.
But again, there are some loopholes.
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Urgent Care facilities are not included, unless the facility is licensed for emergency care.
If your doctor sends your test results to an out-of-network lab, the lab can balance bill you.
"Lab and lab work can oftentimes fall outside the No Surprises Act," explained Pierce. "Also, ground ambulance service. Very few ground ambulance services are part of in-network systems."
That's right, most ground ambulances are not included. So what can you do?
"When consumers are looking at medical care, they often ask if a provider accepts or takes their insurance. That’s not the question to ask. You want to ask whether you are in-network," suggested Pierce.
Meantime, Olaussen says she believes hospitals should audit their providers.
"If they are balance billing and being unethical with their billing practices, then stop doing business with them," said Olaussen.
If you receive an unexpected balance bill from an out-of-network provider, first ask the provider and your insurer to correct the bill.
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If that fails, you can file a complaint with Centers for Medicare & Medicaid Services at 1-800-985-3059.
Texans can find information on fighting balance billing here:
If you cannot refute a bill, you can ask for hospital charity care to pay it, or contact a patient advocate or credit counselor to help.
The three credit bureaus, TransUnion, Equifax, and Experian, announced they are removing cleared medical debts from credit reports in July. You'll also have a year before medical debt will appear on your credit report.
Starting in 2023, medical debt in collections under $500 will no longer be included on credit reports.