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Navigating, negotiating and understanding your medical bills with new ‘No Surprises” Act

The 'No Surprises Act' and your medical bills
Published: Feb. 17, 2022 at 7:58 AM CST
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SIOUX FALLS, S.D. (Dakota News Now) -A medical crisis can cause fear and anxiety. So can opening up the medical bills as they arrive in the mail.

Help is available from organizations like The Patient Advocate Foundation, a non-profit that helps patients with catastrophic illnesses understand and negotiate their medical bills. Patient advocate Caitlin Donovan finds the work fulfilling.

“The best part of our day is when we get notes from patients telling us how relieved they are and it happens frequently. Especially when they’re trying to recover or just deal with a chronic or debilitating condition,” said Donovan.

If it seems difficult to understand your medical bill, you’re not alone.

“How convoluted and complicated medical billing and everything kind of around health care is,” said Donovan.

The South Dakota Attorney General’s office assists patients with questions about their bills. Jody Gillaspie says one procedure alone can have multiple billing codes to reflect individualized care. If you have an appointment booked, you can contact the provider’s billing department, get a few of the procedure codes.

“Have those procedure calls that I can go back to my insurance company to say, this is what they’re looking at. You know, does that get me my deductible met and what is an estimated cost that I can start setting aside those funds? To pay for this procedure,” said Gillaspie.

If you’ve already received medical care, one of the best tools to understand your bill is the explanation of benefits.

“And that’s that packet that comes in the mail that says this is not a bill on it. And most people think this is not a bill and it goes straight into the trash to keep that,” said Donovan.

“Make sure you match up your explanation of benefits with your itemized statements, to make sure that there isn’t anything that is inaccurate on both of those,” said Gillaspie.

The attorney General’s office of consumer protection also helps patients receive a complete itemization of their bills.

Once you’ve verified your claims have been submitted to your insurance and you’re facing an overwhelming bill, Donovan says to call the provider.

“One is asking for the overall and overall discount. Another is asking if there’s a cash price,” said Donovan. “They have an entire system set up to be able to negotiate your bill to try and figure out whether or not they can just send it to collection except pennies on the dollar, or just waive that Bill altogether and there’s no reason that you can not call and ask for a discount or ask if they can waive your bill. The worst they can say is no. If they say yes, you probably saved a lot of money.”

The US Department of Health and human services revealed that Two-thirds of all bankruptcies filed in the United States are tied to medical expenses. The new “No surprises bill” that took effect on January first, designed to ease the financial burden.

As insurance companies and providers adjust to the “No surprises act” it’s important to keep an eye on your medical bills.

Although the act was designed to alleviate the shock of out-of-network costs for patients, the adjustment to review and help patients if they do get charged has required some quick action by the state according to Jody Gillaspie with the consumer protection division of the Attorney General’s Office.

“Wow, it’s not only going forward, it’s implemented already. And so that was kind of surprising to us that there wasn’t more on the forefront or prior to it becoming effective,” said Gillaspie.

Gillaspie describes the sticker shock of a medical bill.

“You’re actually seen in that facility, but yet you’re getting billed out of network. Even though everything was done within that facility. It’s because those entities are not part of that provider. So they get billed as an out-of-network cost,” said Gillaspie.

Patients have received out-of-network bills for in-network hospitals and clinics for services such as a specialist to read results, or an ambulance ride in Sioux Falls to an in-network hospital.

Advocate Caitlin Donovan says the No surprises act will end those practices.

“If you are seeing any type of provider that would fall under this Act, in a facility that would fall under this act, they have to give you 72 hours good faith notice they’ll let you know if there’s another provider in that facility who could do that in-network. And they have to give you the opportunity to go someplace else and they have to give you a good faith estimate,” said Donovan.

Donavon says to avoid out of network costs, even with the new act in place, it’s very important to ask the right questions:

“Make sure you say are you in my network? Not just do take my insurance because they might take your insurance and then when you get there they say surprise. We’ll submit this and see if they give us anything and then we’ll bill you if they don’t and that’s not what you want at all,” said Donovan.

The act is changing emergency air transportation, which is important for patients who live a long distance from a care facility.

“Well, one of the big things especially where you are right now is that air ambulances are now included and they can’t surprise bill you and for people in some of these really large states sometimes they have to be air ambulanced to out to another hospital. And hopefully, that won’t happen anymore,” said Donovan.

The act also ends balance billing, when a provider charges a patient the remainder of what their insurance does not pay.

Both Avera Health and Sanford Health are ready to help with billing questions. We also asked for their input regarding the No Surprises Act and air ambulance services:

Sanford and the No Surprises Act

“Sanford Health’s integrated system continues to provide quality access and affordable health care to its patients. At the end of the day, the No Surprises Act helps patients in our communities avoid surprise or unexpected costs due to certain out-of-network health care services. It prevents patients from being wrongfully billed in situations where they don’t have the immediate option to choose where they receive care. These situations can include emergency room visits, air medical services or coverage for out-of-network providers who provide services within the patient’s in-network facility.” - Stephanie Wessels, Sanford Health Plan principal strategic & operations advisor

Air Ambulance Statement

“When patients need immediate transportation by air ambulance, they often don’t have the time to search for an in-network transport company. Under the No Surprises Act, patients are charged their in-network rate for air ambulance services and any outstanding billing is negotiated directly between the insurance carrier and the air ambulance operator.” - Stephanie Wessels, Sanford Health Plan principal strategic & operations advisor

Avera Statement:

Avera has been supportive of price transparency efforts since the federal regulations were announced. We support protecting patients from unexpected medical bills and remain committed to providing consumers with pricing transparency including easily accessible, understandable and reliable information about health care costs.

Avera launched a consumer-centric price estimator that provides out-of-pocket cost estimates for shoppable health care services. The tool launched at the end of October 2020 in the “Patients and Visitors” section of Avera.org.

In addition, more information is available about surprise billing or how to receive a good faith estimate on Avera.org.

Helpful information:

Federal Government site to discover more and file a complaint, or call their help desk at 1-800-985-3059.

South Dakota No Surprises Act information.

Letter of enforcement from the Federal Government to South Dakota Directors.

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