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  • Cameron Oglesby

One less unpleasant surprise to worry about

Hospital stays cure illnesses, heal injuries, and save lives, but they’re not exactly fun-filled experiences. One thing that’s even less fun is returning home and finding a big, unexpected hospital or ambulance bill in the mail.

In 2020, the Federal Reserve Board found that around 40% of Americans would have a hard time paying a $400 medical bill. A more recent MITRE-Harris poll found that 75% of health-insured Americans have some level of concern about medical bills. Maybe that’s because more than 40% of the respondents said their insurers had billed them for something they’d thought was partly or fully covered.

The No Surprises Act, which Donald Trump signed into law in December 2020, and which finally took effect the beginning of this year, is designed to cure that. Or most of it.

To begin with, the No Surprises Act requires health care providers and facilities to give Medicare and other insured patients advance cost information, including out-of-network costs. It also requires out-of-network providers to get your explicit, informed financial consent to paying for those charges.

It also bans surprise medical bills and what’s called “balance billing” from out-of-network doctors and hospitals for emergency and non-emergency medical services.

A surprise bill is one from a provider outside your Medicare HMO or PPO network. For example, emergency room visits, even out of network, have always been covered. But if an out-of-network radiologist reads your X-rays there and bills you, that’s surprise billing.

If you need non-emergency care when you’re outside your plan’s geographical coverage, or if you choose a local doctor or hospital that’s outside your plan’s network, there may be a difference between what the out-of-network provider charges and what your plan pays. That’s balance billing.

One kind of surprise billing the law won’t prevent is ground ambulance bills, which average $450. Ten states offer some protection from surprise out-of-network ground ambulance bills. Virginia isn’t one of them.

In addition to the No Surprises Act, 33 states have consumer protection laws regarding medical bills. Virginia’s are among the most extensive of them. The Commonwealth prohibits out-of-network providers from billing for any amount above HMO and PPO members’ in-network costs sharing level and requires insurers to hold patients harmless for any amounts above their in-network copays and deductibles. In addition to emergencies, these protections apply to non-emergency surgery, anesthesiology, pathology, radiology, lab and hospitalist services. (But as I mentioned above, they don’t apply to ground ambulances.)

Nobody likes spending money needlessly. But with senior care, that can be all too easy to do. That’s because too many providers match up clients with a list of services, rather than matching services to their clients. So it can be all too easy to end up paying for a nurse’s services when a housekeeper’s or home aide’s will do just fine. Or for moving to an assisted living facility when some home modifications and home help will let clients carry out activities of daily living while aging at home.

That’s why, before we recommend any level of care, we conduct a thorough, three-part needs assessment, It covers not only the client’s physical, cognitive, emotional, and psychosocial health, but also the clients’ and their families’ preferences and priorities. The result is a holistic, coordinated senior care management plan custom-tailored to each individual we serve.

So please contact us to learn more. You could be in for a very pleasant surprise.

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