Understanding and managing medical bills: What you need to know about the No Surprises Act

By Tom Grote, Banner|Aetna CEO

Navigating a serious health issue is overwhelming enough without having to worry about unexpected bills from doctors or facilities. These “surprise” bills often occur because of a process known as balance billing, where an out-of-network care provider bills additional costs after a patient receives care. These surprise bills are often frustrating—and even financially devastating for individuals and their families. Patients can get stuck paying much more for the same care they could have received in-network – even during an emergency, or when they didn’t know the provider or facility wasn’t part of their network. 

New regulations and programs are making it easier for consumers to know exactly how much they will pay for services upfront, so managing medical bills is simpler. A federal bill called the “No Surprises Act” went into effect at the start of 2022 and is one way the government is stepping in to protect people. The “No Surprises Act” bans the following practices for people who get health coverage through an employer, a Health Insurance Marketplace^®, or an individual health insurance plan:

• Surprise bills for most emergency services, even if you get them out-of-network and without approval beforehand (prior authorization).
• Out-of-network cost-sharing, like out-of-network coinsurance or copayments, for most emergency and some non-emergency services. Coinsurance is a percentage of the total bill that the consumer pays, and copays are usually a flat fee paid up front for care. Thanks to this bill, you can’t be charged more than in-network cost-sharing for these services.
• Out-of-network charges and balance bills for certain additional services (like anesthesiology or radiology) furnished by out-of-network providers as part of a patient’s visit to an in-network facility.

This bill will also require that health care providers and facilities give you an easy-to-understand notice explaining the applicable billing protections and who to contact if you have concerns that a provider or facility has violated the protections. It will also state that patient consent is required to waive billing protections (i.e., you must receive notice of and consent to being balance billed by an out-of-network provider).

In Arizona, there are also laws in place to prevent surprise billing and provide dispute resolution for patients. One of the main differences between the two laws is that the Arizona bill is an insurance regulation (only applies to fully insured plans) and the federal bill is directed at doctors and insurance companies (fully insured and self-insured plans).

Some innovative health insurers like Banner|Aetna are also looking to simplify medical billing for patients. Industry thought leader and Banner|Aetna executive vice president and chief medical officer Robert Groves, MD recently spoke as part of a panel with Becker's Hospital Review about some of the ways the organization is working to improve the member billing experience. 

A first-of-its-kind program from Banner|Aetna called “frictionless billing” will combine the many different charges from certain providers with the insurer’s explanation of benefits (EOB) into one easy to read document. (EOBs are statements from insurers that explain how insurance benefits are applied and what the member may still owe.) Consolidating the information will make it easier for members to see what they’ve paid, what the provider billed, and what is still owed. This is only possible because of the unique relationship between Banner Health and Aetna, and will be especially helpful for hospital stays where facilities, anesthesiologists, doctors and other care providers may all bill a consumer separately.

If you’re already a Banner|Aetna member, stay tuned for more information about this program soon. If you’re not a member, and you’re interested in learning more about our coverage, visit our Employer or Individual coverage information here.