Effective today, federal law bans many types of out-of-network medical bills and puts the onus on doctors and health insurance companies to resolve their payment disputes.
Why it matters: Consumers can breathe a sigh of relief because, in many scenarios, they should no longer face unexpected charges from doctors who are not in their insurance networks.
How it works: Patients still have to pay in-network copays, deductibles and other cost-sharing, which have been rising, but any additional out-of-network bills are now prohibited for the following services:
- Emergency care in a hospital ER, a freestanding ER or urgent care center.
- Elective care at an in-network hospital or surgery center, but where doctors — notably anesthesiologists, pathologists, radiologists and assistant surgeons — may be out-of-network. This is also known as "drive-by doctoring."
- Air ambulances.
Of note: Ground ambulances are not included in this law, meaning three out of four insured people who take an ambulance ride are still at risk of facing surprise bills.
Behind the scenes: Instead of sending out bills, doctors and insurance companies have to resolve their differences while holding the patient harmless.
- If the two sides can't agree on a payment rate within 30 days, either side can request the federal arbitration process.
- The doctor and insurer then go to the arbiter with their best offer, and the arbiter picks one.
An important point: The arbiter "must select the offer closest" to the median in-network rate unless other information "clearly demonstrates"...