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Law aiming to protect consumers against surprise medical bills takes effect

ADRIAN FLORIDO, HOST:

Unexpected medical bills from out-of-network providers have been an all too common reality for many Americans. Often they come after a visit to a hospital emergency room. But a new federal law that went into effect yesterday is meant to protect patients from these kinds of unwanted surprises. The legislation, approved by Congress more than a year ago, is called the No Surprises Act.

To help us better understand what this law means for patients, we've called Julie Appleby. She's a reporter with Kaiser Health News, and she joins us now. Julie Appleby, welcome to the program.

JULIE APPLEBY: Thanks for having me.

FLORIDO: Why did Congress tackle this issue? How big of a problem have these unexpected medical bills been for patients?

APPLEBY: You know, these have been a big problem. People have been complaining about this for a while. In fact, some studies before this law passed showed that 1 in 5 emergency room visits and about 1 in 10 elective surgeries resulted in one of these surprise out-of-network bills. So they were hearing about it from their constituents for a while, and people were complaining to their employers. But it still took a long time to sort this out. I mean, Congress was debating this for about two years. It almost passed one year and then at the very last minute failed. And then at the very end of December 2020, it passed. And it was signed into law by then-President Donald Trump, and the Biden administration has spent the last year writing the rules that'll kind of govern how this thing actually works.

FLORIDO: And so how will it work? What does this law mean for folks who might have to go to emergency rooms, for example?

APPLEBY: Well, under the law, basically, the patient is taken out of the middle of these disputes. So the patient is only going to pay the deductible and the co-payments that they would have had, had their care been in-network. Then the law says insurers and the medical providers have to work it out between themselves, what the actual amounts paid will be. So if they can't agree, the law says the two sides have to go to an arbitrator and each of them put up their best offer. And then the arbitrator is going to pick one of those, and that's what the insurer will pay. This law is going to apply broadly to major medical insurance and plans sold to individuals through the Affordable Care Act. Earlier rules said that surprise billing was already banned under Medicare and Medicaid.

FLORIDO: It could still be the case, though - right? - that a patient gets an unexpected large medical bill for an emergency. What does this bill not protect patients against?

APPLEBY: So the legislation doesn't include ground ambulances, for example. And some studies have found that at least half of all ground ambulance rides may result in a surprise bill. So it's quite possible that if you're taken to the hospital in ambulance, you might get a balance bill. It's not retroactive.

FLORIDO: OK.

APPLEBY: So if you incurred any of this in 2021, you might still be on the hook for these bills. The law also does not apply to nonemergency services provided in other facilities, things like addiction treatment centers and nonemergency mental health counseling. So it's possible people might get a surprise bill there. And then urgent care centers are kind of an interesting gray area that we're going to have to watch because the rules governing how this law works say that the protections apply to urgent care clinics that are licensed to provide emergency services. But many urgent care facilities are not licensed specifically for emergency services. So kind of the bottom line - it remains a good idea for consumers to check first in sort of nonemergency situations that the facility or the provider they're selecting is in network. For emergencies, you can feel a lot more confident that this law will cover you.

FLORIDO: What should people do in the new year if they get a big bill that they think might run afoul of this law?

APPLEBY: Yeah, absolutely. If they get a bill that they think does run afoul of the law, they should contact their insurance plan and appeal and say, hey, I think that I'm being unfairly billed here. They should contact the person who sent it to them, the same thing, and raise that issue because they do have these protections now.

FLORIDO: That was reporter Julie Appleby of Kaiser Health News. Julie, thanks for being with us today.

APPLEBY: You're welcome.

(SOUNDBITE OF RADIOHEAD SONG, "NO SURPRISES") Transcript provided by NPR, Copyright NPR.