**Insurance Billing Unveiled: Understanding Your Policy And Payment**

In the United States, the No Surprises Act, which came into effect on January 1, 2022, protects individuals from surprise or balance billing in the case of emergency care or when treated at an in-network hospital by an out-of-network provider. This means that if an insurer and provider cannot agree on a price for covered services, they must resolve the issue through arbitration and cannot bill the consumer for the disputed amount. In such cases, the insurer must pay the out-of-network provider directly, and the consumer is only responsible for their in-network cost-sharing. Additionally, HIPAA/HITECH regulations allow patients to opt out of filing their health insurance, as long as they pay the provider in full.

Patients can opt out of insurance if they pay in full

Patients can opt out of insurance and pay in full for their treatment. This is known as "self-pay".

HIPAA/HITECH regulations allow patients to opt out of filing their health insurance, as long as they pay in full. This is supported by the 2010 Health Information Technology for Economic and Clinical Health (HITECH) Act, which states that a healthcare provider must honour a patient's request to restrict the disclosure of their protected health information (PHI) to a health plan, if the patient pays the healthcare provider out of pocket in full.

If a patient chooses to opt out of their insurance, they should sign an "election to self-pay" form. This form outlines that the patient has chosen to opt out of their insurance, and that the healthcare provider will not file a claim with their insurance company. The patient will then receive a receipt for their visit.

It is important to note that this does not apply to Medicare patients.

In the case of Medicaid, a patient can opt out of their primary insurance being billed, but Medicaid will require the primary to be billed for Coordination of Benefits (COB) purposes.

The No Surprises Act protects against unexpected out-of-network charges

The No Surprises Act (NSA) is a federal law that came into effect on January 1, 2022, to protect people from unexpected medical bills. The Act aims to help patients understand healthcare costs in advance and minimize unforeseen medical bills. It protects people covered under group and individual health plans from receiving surprise medical bills when they receive most emergency services, non-emergency services from out-of-network providers at in-network facilities, and services from out-of-network air ambulance service providers.

The NSA establishes an independent dispute resolution process for payment disagreements between plans and providers and provides new dispute resolution opportunities for the uninsured and self-pay individuals when they receive a medical bill that is substantially greater than the good faith estimate they get from the provider.

Under the NSA, surprise bills for emergency services from an out-of-network provider or facility and without prior authorization are banned. Out-of-network cost-sharing, like out-of-network coinsurance or copayments, for all emergency and some non-emergency services are also banned. Out-of-network charges and balance bills for certain additional services (like radiology or anesthesiology) furnished by out-of-network providers as part of a patient’s visit to an in-network facility are also banned.

The NSA requires that healthcare providers and facilities give patients an easy-to-understand notice explaining the applicable billing protections, who to contact if the patient believes the provider or facility has violated the protections, and that patient consent is required to waive billing protections.

If you don’t have insurance or you self-pay for care, in most cases, these new rules ensure that you can get a good faith estimate of how much your care will cost before you receive it. If you are billed for an amount that is at least $400 more than the total amount on the good faith estimate, you may dispute the charges in the Federal patient-provider dispute resolution process.

Surprise billing and balance billing

To protect consumers from surprise billing, the No Surprises Act (NSA) was implemented on January 1, 2022. This Act protects people with group or individual health plans from receiving surprise medical bills for most emergency services and some non-emergency services from out-of-network providers at in-network facilities. It also establishes an independent dispute resolution process for payment disputes between insurance plans and providers. Additionally, the NSA requires health care providers and facilities to disclose patient protections against balance billing and sets forth complaint processes for violations.

If you receive a surprise bill, you can contact the provider or facility and inform them that you believe you have been wrongly billed. You can also file a complaint with the appropriate office, which will investigate on your behalf. It is important to note that you are not responsible for paying a surprise medical bill, and your insurer must pay the out-of-network provider directly. You are only responsible for your in-network cost-sharing, including copays, coinsurance, and deductibles.

To further protect yourself from surprise billing, you can request a "good faith estimate" of the expected charges from your provider before receiving treatment. This estimate should be provided to you in writing and can be used to dispute your bill if it exceeds the estimate by a significant amount.

Good faith estimates

In the United States, the No Surprises Act, which came into effect on January 1, 2022, protects individuals from surprise or balance billing. This includes emergency care, emergency behavioural health services, and scheduled procedures at an in-network facility where care is provided by an out-of-network provider.

The Act also introduced Good Faith Estimates (GFEs), which mandate healthcare providers and facilities to provide price estimates to the uninsured or self-pay patients who decide not to submit claims to their insurers when they schedule care. This is required even if the provider or facility won't be providing all the services. GFEs for insured patients are not currently mandatory, but final rules to make them mandatory in the future are still pending.

If you are uninsured, you have the right to receive a good faith estimate of the amount you will be billed for scheduled or non-emergency items or services. This estimate should include costs for items and services anticipated to be provided with the visit, such as medical tests and hospital fees. You are entitled to receive the estimate in writing at least one business day before your scheduled medical service or item. You can also ask your healthcare provider for a good faith estimate before you schedule an item or service.

If you are insured, you may also request a good faith estimate of the amount you will be billed for non-emergency items and services that you might like to schedule. Whether or not you have insurance, if the estimate you receive for the anticipated items and services substantially exceeds the amount billed to you, you can dispute the bill.

Patients' rights

Patients have a variety of rights that are protected by federal, state, and health plan laws. These rights include access to quality healthcare, the ability to opt out of insurance, and protection from surprise or balance billing. Here is a detailed overview of these rights:

Right to Quality Healthcare

The Patient's Bill of Rights, announced by President Obama in 2010, guarantees patients access to quality healthcare. This includes the right to choose a primary healthcare provider from a list of participating providers and the freedom to change medical providers if necessary. Patients are also entitled to prompt and appropriate referrals to specialists and direct access to a chiropractor if their plan covers chiropractic care. Additionally, health insurance companies and providers are required to maintain the confidentiality of patient information unless given written permission to disclose it.

Right to Opt Out of Insurance

Patients have the right to opt out of filing their health insurance, thanks to HIPAA/HITECH regulations. However, if they choose to do so, they must pay the provider in full. This option allows patients to make informed decisions about their financial responsibilities, especially if they have high deductibles or prefer to pay out of pocket for certain services.

Right to Protection from Surprise Billing

The No Surprises Act, which came into effect on January 1, 2022, protects patients from unexpected medical bills. It applies to most types of health insurance and shields patients from out-of-network charges for emergency room visits, non-emergency care related to visits to in-network facilities, and air ambulance services. This law ensures that patients won't be burdened with unexpected costs when seeking medical attention.

Right to Good Faith Estimate

When patients don't use health insurance or choose to pay for care without using their insurance, they are entitled to receive a good faith estimate of the expected charges. This estimate can be requested when scheduling care at least three business days in advance or by directly asking the provider. If the final bill exceeds the estimate by at least $400, patients have the right to dispute the charges.

Right to Dispute Surprise Bills

In the event of receiving a surprise bill, patients can take several steps to protect themselves. They can contact the provider or facility and inform them of the incorrect billing. Additionally, they can file a complaint with the appropriate office, which will investigate the matter on their behalf. Patients also have the right to appeal if their health plan denies all or part of a claim for service.

These rights empower patients to make informed decisions about their healthcare, protect their financial interests, and ensure they receive fair and transparent treatment from healthcare providers and insurance companies.

Frequently asked questions