In 2017, a California law was implemented to prevent “surprise bills” from out-of-network medical providers who work at in-network facilities. But when nearly 6 million Californians are blindsided with medical bills from practitioners not contracted with PPOs, it is clear that this 2017 law is not enough. The law does not protect those who get health coverage through employers that pay employee medical bills out of pocket. “Self-funded” plans are instead regulated by the U.S. Department of Labor, beyond the control of state policy.
However, a federal law which took effect in the new year ensures for over 100 million people across 32 states that this will not continue to occur. The new No Surprises Act protects nearly 1 million California residents not covered by the 2009 CA Supreme Court ruling that prohibits emergency room doctors and other providers of emergency services from billing HMO patients for out-of-network charges not paid by their insurers – otherwise known as balance billing.
The new law will prohibit patients from getting bills for services when they unknowingly receive care from most out-of-network providers. Existing law already protects members in HMO plans from surprise billing, while Medicare and Medicare Advantage plans have their own protections. The Knox-Keene Act, which governs most HMOs in CA, prevents emergency-room doctors and practitioners from billing HMO patients for services, while AB-72 provides that if an HMO patient receives services at an in-network facility by an out-of-network physician, the patient is only required to pay the in-network price for such services.
The No Surprises Act further allows providers and facilities to attempt negotiations for a satisfactory payment with the plan, given that they are not satisfied with an initial payment from a health plan for out-of-network services. When an appropriate amount cannot be negotiated, the provider can submit a claim to an independent dispute resolution process to determine the appropriate payment amount. The law most notably gives patients a good faith estimate of expected charges for scheduled services upon request.
This act is a result of work done by insurance providers who supported this federal action by briefing Congress members and their staff on patient experiences, as well as providing educational seminars on CA law. Ultimately, this act will allow people who were otherwise unable or unwilling to pay for surprise bills from emergency room visits considered out-of-network to be protected. However, there is still a long way to go for the uninsured, and those across the country who are not protected and covered by state programs for the disadvantaged.
This blog post is part of the CIMA Law Group Blog. If you are in need of legal help, the CIMA Law Group is a law firm in Phoenix, Arizona which possesses expertise in Immigration Law, Criminal Defense, Personal Injury, and Government Relations.
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