By Jacob Mathew, DO
There are certain times in life when we want to be surprised: birthdays, celebrations, or get togethers in general. Sticker shock at a car dealer or showing up to the airport to find our flight is delayed (or maybe not even there) is definitely not surprises we want. More recently however, patients have found another that has hit them and insurance companies in the pocket books: when out-of-network providers sneak into their care and then bill them without their knowledge. No more. Effective Jan. 1, 2022, the No Surprises Act went into effect and its important that you know what it is.
It bans surprise billing for emergency services from an out-of-network provider or facility and without prior authorization.
It is not retroactive, meaning you cannot file complaints regarding events that took place before this date, but after this date, you should if you felt they apply. It is not uncommon for providers, especially surgeons, to use out-of-network assistants (such as Physician Assistants) during procedures. In a non-emergent situation (called the post-stabilization period), you will often find them come to your bedside with a notice and consent form to fill out and on that form it will typically state that they may be out of your network and, as such, you may be charged separately for billing. You are not required to sign such paperwork and you have the right to have someone within network care for you during your case. Know that by doing so, it may result in you having to reschedule your care.
Colorado has its own form of this law, which went into effect on Jan. 1, 2020.
Am I already covered?
- Yes, if you have TRICARE, Veterans Affairs Health Care, Indian Health Services Care, Medicaid or Medicare
Who is not covered?
- Those without health insurance (instead by law you should receive a good faith bill up front)
- If the bill you receive is more than $400 above the estimate than you are advised to dispute the bill within 120 days of the date on the bill
- Those not in an emergency situation (see description above regarding post-stabilization)
What services are covered?
- Surprise bills for emergency care even if you get them out of network without prior approval
What steps should I take if I think I am affected?
1. Before you pay: Contact your insurer about the bill
Ask for clarification. Make sure that your insurer received a claim for the services for which you’re being billed. Ask if you are being held responsible for part of the billed amount, or for the entire bill.
2. File a complaint with your insurer, aka an ‘internal appeal’
If your insurer does not agree to pay the claim, and you think it should be covered, you have the right to appeal within 180 days of your denied claim. An appeal means that you are asking your insurer to reconsider their decision not to pay. Keep in mind that if your bill is a true balance bill, the insurance company may not have been asked to pay and you can send them a copy to take care of it for you.
Important reminder: Document all phone calls and keep copies of all paperwork.
If the problem is not resolved:
3. File a complaint to the Colorado Department of Insurance
Through an external, or third-party appeal, the Department of Insurance will review your claim within 60 days of the denied internal appeal
Who do I contact if I have questions?
- If you have a question about the No Surprises Act or believe the law isn’t being followed, contact the Centers for Medicare & Medicaid Services No Surprises Help Desk at 1-800-985-3059 from 8 a.m. to 8 p.m. EST, 7 days a week, to submit your question or a complaint. You can also submit a complaint online at the consumerfinance.gov website or the Colorado Consumer Health Initiative at 303-839-1261
- For Colorado residents you can file a complaint with the Division of Insurance at https://cohealthinitiative.org/need-help/surprise-medical-bills/
Plan to attend our in-person event COMMUNITY, CONNECTION AND LAUGHTER, the PCMS Dinner Social on Wednesday, Nov. 16, 6 p.m. The purpose of this essential social is to foster a sense of community, connection and laughter for members and guests in a time when the value of togetherness is at an all-time high. Watch for more information coming soon! Questions? Please contact us.
Save the date for our annual online event ARISE, the PCMS Annual Meeting, on Wednesday, Sept. 28, at 6 p.m. The purpose of this informative meeting is to emerge from this pandemic and offer members a chance to ask questions of the board and officers of the medical society and to introduce the new fiscal year in review. This meeting is open to all members to attend virtually via Zoom. It will include programming for medical providers and the election of new board members. Watch for more information coming soon! Questions? Please contact us.
You and a guest are invited to attend our next event coming up June 30, 2022 at 6 p.m. at 4 of Harts Restaurant, 102 S. Union Ave., Pueblo, CO 81003. SHJ Wealth Advisors will hold another dinner and financial presentation. The March event was highly praised, with top-notch food and great conversation. RSVP to [email protected].
Mark your calendar and spread the word: Puebloans can dispose of bulky items during Team Up to Clean Up on May 21 at two sites. More information and pre-registration is available here.
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