Attorney Heather Macre explains new surprise billing law

Surprise medical bills can be shocking for insured patients who sought care at an in-network hospital but were treated by out-of-network providers. We spoke to Phoenix attorney Heather Macre about the federal “No Surprises Act” that went into effect in January.

“Surprise medical bills typically happen when a patient goes to a facility to get medical facility to get medical services, and they think that they’re going to an in-network facility, but they unknowingly see an out-of-network provider there, and so they receive a much larger bill because it isn’t covered,” Macre said. “It can be a reason to deny a claim, or it can be a reason to charge a much higher amount for a claim,”

In these cases, consumers would previously be stuck paying an unexpectedly expensive bill.

“Typically what we see is that the consumer gets hit with these out of network costs, which can be three to four times higher than what they’re expecting to pay. The claim might not be denied, but it will be covered at a much lower rate, leaving the consumer with a much larger bill,” Macre said.

The bill specifically covers three scenarios. First, if a consumer goes to an in-network location but is seen by an out-of-network provider, they must be provided with the choice to see an alternative provider, or opt-in to paying the out-of-network costs. The other two scenarios cover emergency situations, where a patient requires emergency treatment or medical transportation and doesn’t have the opportunity choose any alternative.

However, the bill does not cover all medical plans. Government-funded medical plans, like Medicare and Medicaid, as well as plans that are self-funded by an employer are not covered by the bill, Macre said.

“But I always caution folks, even if you are on a plan where this does not apply, that doesn’t mean that you might not have rights,” Macre said. “You always have the opportunity to work with your insurance company and see if there’s a way to work out these kinds of bills.”

Additionally, Arizona had already passed a state-wide measure which established a resolution process for surprise medical bills called SOONBDR, which may potentially cover some situations not covered by the No Surprises Act.