New laws protect Ohioans from surprise billing

Credit: DaytonDailyNews

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Surprise billing

Credit: DaytonDailyNews

Ohioans are newly protected against many of the surprise high bills that come when patients accidentally go out-of-network when seeking health services.

The protections come from two new laws, one at the state level effective Wednesday and also a federal law in effect since Jan. 1.

These laws take aim at a practice often called surprise billing, which can happen when patients accidentally get medical services from an out-of-network provider at an in-network hospital. Ambulances, medical helicopters, emergency physicians, anesthesiologists and more can all be part of separate businesses that might not be in the patient’s insurance network.

ExploreMedical billing surprises? New Ohio, federal laws aim to protect patients.

The patient is then stuck with the balance between what the medical provider charges and what the insurance pays.

Now, patients who go out-of-network when getting emergency care shouldn’t receive bills for more than if they had been in network. Patients are also protected from out-of-network bills in some non-emergencies. If they do get the bills, there’s a system to report the problem.

It is now the health care provider’s and the health insurer’s job to work directly with each other over price and payment disputes in these situations.

“That’s what we’ve all been working toward,” said Ohio Department of Insurance Director Judi French. “To take the burden off of consumers in both those emergency situations and non-emergency situations.”

Here are some key facts to know about the changes:

What kind of bills does the law protect people from?

People are protected from surprise billing in emergencies and some non-emergencies. Some examples of situations where people are now protected include:

  • Emergency care, including any treatment or transports needed to get stabilized.
  • Unanticipated out-of-network care when the person did not have the ability to request the service from an in-network provider.

Ohio Department of Insurance said this includes when someone with insurance schedules an elective treatment or nonemergency care appointment with an in-network health care provider, but receives services from an out-of-network health care provider, such as for an x-ray or lab service.

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“You know who your surgeon is, but what you might not know is that somebody in that room, for example an anesthesiologist, is not in your network, and so you get what we might call the balance bill ... in that situation, you had an opportunity to do your homework, you did it, and yet you still got this surprise bill,” French said.

Under the new law, the patient is now protected from being billed the balance.

For more details, people can go to insurance.ohio.gov or call 1-800-686-1526.

What kind of bills do people still owe?

There are other types of bills patients can still get when getting in-network hospital care, such as a deductible, co-payment or co-insurance.

What if someone has a surprise bill they owe from 2020, before the laws went into effect?

The patient still owes that bill.

If you still get a surprise bill

If you think you were sent a bill you shouldn’t have to pay, first call your insurance company about fixing the error.

If this doesn’t fix the problem, contact the Ohio Department of Insurance at 1-800-686-1526, consumer.complaint@insurance.ohio.gov, or through insurance.ohio.gov.

Ambulance billing protections depend on your insurance

While the state and federal laws are similar, they aren’t exactly the same. One important difference is that only the state law includes protections from surprise bills from being driven in an ambulance.

This means that people with fully-insured plans are protected from these ambulance surprise bills, but people with what are called self-insured plans are not. If your insurance is through your job, it can be hard to tell at a glance what kind of insurance you have, so ask your employer to find out. Generally, big companies are self-insured.

Medical helicopters, sometimes called air ambulances, are covered under the federal law so everyone should be protected.

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So who pays for the surprise bill?

Instead of sending the patient the balance, the insurance company and health care provider have to hash it out.

A health insurer’s payment to the health care provider will be the greatest of the following three amounts:

  • The median in-network rate for the services for the geographic region in which the services were performed,
  • The out-of-network rate, also called the usual, customary, and reasonable rate,
  • Or the Medicare rate for that service.

The health care provider can also negotiate with the insurance company, and if needed there’s an arbitration process set up under the law, where the provider can take the dispute in lieu of accepting the health insurer’s reimbursement amount.


Coming Sunday

On Sunday, this newspaper will be reporting more on the new surprise billing law. If you have more questions about what the law means, email Kaitlin.Schroeder@coxinc.com.

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