A few years ago, I did the right thing and had a colonoscopy. At my age, and because my mom had colon cancer, I was glad that my health insurance would cover this preventive screening procedure.
My primary care doc referred me to a gastroenterologist in the same medical building. He would do the procedure in his office. Of course, I checked to make sure the gastroenterologist was “in-network” with my health insurance plan, so that the procedure would be covered with only a reasonable co-payment.
While nothing is really convenient about a colonoscopy (especially the colonoscopy cocktail that comes the night before), this seemed to be a relatively stress-free and uncomplicated way to navigate our health system and get the screening I needed.
Needless to say, no one wants any surprises when it comes to a colonoscopy. The day of the screening went smoothly, and I remember nothing of the actual procedure. I was a little slow coming out of anesthesia and, when I did, I was in a big La-Z-Boy lounge chair and apparently had been asking quite urgently for my “free cookies” while still slightly under. Hey, this girl has her priorities.
My screening revealed no problems, and so I gained both a free cookie and the peace of mind of knowing I remained free of colon cancer. When the time comes for another colonoscopy — five years later in my case — I won’t hesitate to take this step to protect my health. I’d say to anyone whose medical provider recommends a colonoscopy — do it. It is not a big deal.
But now for the rest of the story. My colonoscopy did include a surprise — not related to my health but to my wallet. Several days after the procedure, I received a bill from the gastroenterologist practice. It included several separate bills for services related to the colonoscopy.
How much? A lot.
While the gastroenterologist was “in-network” with my health insurance plan, the anesthesiologist was not. That meant I had a very large and unexpected bill for his services. I remember arguing with the practice that, surely, this cannot be right. Anesthesia is not considered optional for a colonoscopy and no one had mentioned that the anesthesiologist was not part of the “in-network” practice. It was a total “gotcha” moment when the front desk receptionist said to me, “I am sorry ma’am that you didn’t ask us about your insurance covering the anesthesiology services.”
Say what? Should I have asked about the cookie, too?
Surprise bills like these have been very common over the past 20 years. Mine is just one example. A hospital stay — even if an emergency situation — often resulted in a mish-mash of in- and out-of-network providers and unexpected high bills, even with health insurance coverage.
But this story has a happy ending. There are no more surprise bills for patients like me. A new federal law, the No Surprises Act, will go into effect Jan. 1, 2022, that will largely eliminate surprise medical bills. The first regulation under the law was published in the Federal Register.
The new law and regulations will:
(1) Prohibit individual and group health insurance coverage, federal employee health plans and out-of-network health care providers, facilities and air ambulance services, from imposing surprise bills.
(2) Limit patient cost-sharing to the amount that would have applied if the provider was in-network.
(3) Require notice to patients regarding these protections and a complaint process.
Looking back at my situation, the new law would have protected me from the high bill for my colonoscopy anesthesia services. Surprise medical bills are always prohibited “in certain circumstances where surprise bills are likely to occur, such as for ancillary services provided by nonparticipating providers in connection with non-emergency care in a participating facility.”
The new regulations also prohibit plans from denying coverage for non-emergency use of a hospital emergency department if the patient’s symptoms would have led a reasonable layperson to conclude that the patient needed emergency treatment.
Just one other note about the No Surprises Act: It offers an encouraging illustration of members of Congress standing together to pass laws that help working Americans. We need to see that people-first approach more often.