Surprise medical bills can be extremely frustrating, even devastating for healthcare recipients, and the practice of sending them is often unfair to both patients and providers.
America’s Medical debt problem is something that is more common than you may think, over 20% of Americans are plagued with it. Congress has finally taken a step towards curtailing these surprise charges that have plagued our healthcare system for too long, with their support for the “No Surprises Act” (NSA).
In the CareTalk episode, “Has Surprise Billing Met Its Match”, hosts John Driscoll and David Williams are joined by Yale professor and health economist, Zack Cooper to discuss surprise medical bills and how his research helped drive the No Surprises Act legislation.
Surprise Medical Bills Explained
Surprise medical bills are a type of unexpected charge that patients may receive for medical services that their health insurance does not cover. These bills occur when a patient receives care from an out-of-network provider or an in-network provider uses an out-of-network service. In these cases, the patient may be responsible for paying the difference between the provider's charge and the insurer's payment, resulting in unexpected and often exorbitant bills.
These “surprise” bills are a growing concern for patients and their families and a major contributing factor behind why healthcare is so expensive in the US.
Patients may not be aware that they are receiving care from an out-of-network provider, particularly in emergency situations where they may not have the ability to choose their provider.
Additionally, many patients may not fully understand the terms of their insurance coverage, which can leave them vulnerable to unexpected charges. The issue of surprise medical bills has become a focus for lawmakers and healthcare providers, who are working to implement measures to protect patients from these unexpected and potentially ruinous bills.
“For the privately insured, one in five times, the person went to an in-network hospital in an emergency, they're getting treated by an out-of-network physician”- Zack (CareTalk)
What is the No Surprises Act (NSA) and How Does It Work?
The No Surprises Act (NSA) is a federal law that was passed by the United States Congress in December 2020 as part of the Consolidated Appropriations Act. The law aims to protect patients from unexpected medical bills, particularly those resulting from receiving care from out-of-network providers. The NSA applies to patients with group health plans, including those provided by employers, as well as those who purchase coverage through the individual market.
The NSA includes several key provisions designed to protect patients from surprise medical bills. One of the most significant provisions of the law is the prohibition of balance billing for certain medical services. This means that patients cannot be charged more than their in-network cost-sharing amount for emergency services, non-emergency services provided by an out-of-network provider at an in-network facility, and certain ancillary services, such as radiology or anesthesiology, provided by out-of-network providers at in-network facilities.
Additionally, the NSA requires health insurers and healthcare providers to disclose to patients certain information related to their coverage and cost-sharing obligations, such as estimated out-of-pocket costs, prior to receiving care. The NSA also establishes an arbitration process to resolve payment disputes between insurers and out-of-network providers, which is intended to prevent patients from being caught in the middle of payment disputes.
The Research Behind the No Surprises Act
The No Surprises Act has been a hot-button issue in the United States for some time now. With medical bills skyrocketing and insurance policies becoming increasingly more confusing, many Americans are left feeling vulnerable when it comes to their health care. This is where the research by health economist Zack Cooper comes into play. Cooper's research delves deep into the economic and financial side of medical care, shedding light on the true cost of coverage and the reasons why consumers are often caught off guard by surprise bills.
His work has been a valuable tool for policymakers and healthcare advocates looking to improve the system and provide better protections for patients. Thanks to Cooper's insights and expertise, the No Surprises Act has the potential to be a game-changer for all Americans struggling with the complexities of modern health care.
“We published some work. It was in the New England Journal of Medicine that showed one in five patients got one of these bills. We did a follow up paper that was in the Journal of Political Economy showing that it was really one or two of these big physician staffing companies that we're using that as a deliberate strategy. The paper got a lot of traction, it was on the front page of the Times and Lamar Alexander was really taken by the issue”- Zack Cooper (CareTalk)
Looking Ahead: Shaping the Future of Medical Policies
Overall, the No Surprises Act is an important step to protect patients from surprise medical bills in the future. While there are still some problems with this new law, it’s clear that it can help reduce out-of-pocket costs for Americans who are hit with surprise medical bills. Beyond its practical implications, this act also illustrates how legislation can be used to stop a harmful practice by working together and using data as a tool.
As such, Zack Cooper’s research not only has real-world implications but also demonstrates the power that detailed data and research papers can have on shaping public policy. As we march forward with advancements in healthcare technology and increased demand for equal access to care, the No Surprises Act serves as a reminder of the progress we can make when both sides work together towards a common purpose.
CareTalk is the only healthcare podcast that tells it like it is. Join hosts John Driscoll (President U.S. Healthcare and EVP, Walgreens Boots Alliance) and David Williams (President, Health Business Group) as they provide an incisive, no B.S. view of the US healthcare industry.