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Do I owe medical expenses for out-of-network (OON) medical providers?

Starting Jan. 1, 2022, not anymore for a lot of services.

At the end of 2021, Congress passed the No Surprises Act (NSA), a part of the 2022 omnibus appropriations bill.

It now insulates consumers this cold winter from unexpected bills charged by health providers who were not covered by the consumer’s health insurance plan because the provider was not part of an approved “network” list of providers for that insurance carrier.

But not for all OON services. And patients still have to pay in-network copays, deductibles and such.

The services a consumer is now protected from being billed by OON providers include: 1) emergency care in any hospital ER, free-standing ER or urgent care center; 2) elective care at an in-network hospital or surgery center where any treating doctor — typically anesthesiologists, pathologists, radiologist and assistant surgeons — is out of network; and 3) air ambulances (OON ground ambulances are not in this law so you’re always on the hook for that bill).

The consumer’s non-liability for emergency care or air ambulance protection is applicable only if the patient did not have an opportunity to select the provider or service.

Regarding non-billable OON services, the insurance companies or those providers will have to haggle between themselves for payment of those services and not bill the patient or those under the law who might ordinarily be responsible for that patient’s health care bill.

Health plans, issuers and Federal Employees Health Benefits (FEHB) Program Carriers must pay the OON provider or facility or provider of air ambulance services an amount in accordance with a state All-Payer Model Agreement or specified state law, if applicable. In the absence of such Model Agreement or state law, the plan must make an initial payment or a denial of payment within 30 calendar days.

If the insurance carrier and the health providers can’t resolve their differences within 30 days of a billing, one or both sides can ask for arbitration under the arbitration process set up under the act.

We shall see if this act is challenged by health care providers or insurance carriers as being unconstitutional in interfering with those parties’ Frist Amendment rights to contract.

But until a court says otherwise, fear not if you are helicoptered away from a hideous highway accident by an OON medical helo company.

Health care consumer organizations warn consumers to review their bills carefully to make sure an OON service covered by the NSA has not slipped in. Consumers are urged to contact the provider or the insurance company if something is amiss.

One pothole in the ambulance-to-legal-safety is that health providers can ask the patient to sign a waiver before service once the provider has advised the patient of what the costs might be. In any event, if there is an emergency not affording the opportunity to select the provider, then the issue of pre-warning-of-cost and waiver will not likely arise.

Otherwise, when you get the bill, it could ring like the sound of MASH’s Radar O’Reilly’s announcing an instant before the med-evac chopper blades could be heard: “Incoming!”

Brett Kepley is a lawyer with Land of Lincoln Legal Aid Inc. Send questions to The Law Q&A, 302 N. First St., Champaign, IL 61820.

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