New federal law protects consumers from costly 'surprise' medical bills

FARGO — North Dakota patients who received air ambulance services from a carrier outside their insurance network were stuck with bills that averaged $55,341 in a tally by state insurance officials.

Now, under a new federal law that took effect Jan. 1, consumers will be protected from whopping “surprise bills” obligating them for any amount greater than their insurance paid for out-of-network care.

The No Surprise Bill Act requires out-of-network medical providers and insurance companies negotiate payments when patients receive care outside their health insurance networks. As a result, consumers will no longer be stuck with the balance.

“It takes the consumer out of the middle of these discussions,” said Jon Godfread, North Dakota insurance commissioner. “Ultimately, they shouldn’t be receiving those bills anymore, which is a big win for consumers.”

The new law addresses problems that come up from out-of-network ambulance services, emergency care or out-of-network providers working within an in-network facilities.

In North Dakota, most health systems are integrated, meaning they provide a full range of services within their care network. As a result, surprise bills for routine health care aren’t common, he said.

Traditionally, health insurance plans provided broad coverage, with nearly all providers considered “in network.”

But so-called “narrow network” plans have become increasingly popular in recent years because they come with premiums that can be 10% to 20% lower. Consumers with narrow network plans must be careful to stay within their care network to avoid out-of-network charges.

Now, under the No Surprises Act, medical providers must notify patients if they are out of network.

In North Dakota, the biggest problems with surprise bills came from one or two air ambulance services that didn’t sign contracts with major health insurers, leaving many patients with high, “out-of-network” balance bills.

“It does present some challenges,” Godfread said, because some consumers are confused about which providers are inside or outside their network.

By far, surprise bills from air ambulance services have been the big problem in North Dakota, he said. An analysis by state insurance officials in 2017 found that 18 air ambulance bills ranged from $18,000 to $83,613 and averaged $55,341.

The Sanford Health Plan has created a page on its website for information about consumer protections under the No Surprises Act.

Most out-of-network bills result when people travel and get sick or injured and require care away from home, said Stephanie Wessels, Sanford Health Plan’s principal strategic and operations adviser.

“That’s when a lot of these things occur,” she said. The Sanford Health Plan’s narrow network plans, which require customers to get care from Sanford Health providers, are only sold in areas such as Fargo and Sioux Falls, S.D., where a full range of medical services are available through the organization, Wessels said.

Under the No Surprises Act, the customer isn’t penalized if given care outside the insurance network. “The member’s held harmless, essentially,” she said.

Now the onus is on health providers to alert patients if they are outside the care network. “They’re required to provide this model notice,” Wessels said. “They do have to give them notice.”

Matthew Farrell, Essentia Health’s senior director of access management, said the health system is highly integrated, so offers a full range of services. “We operate as a team,” he said, so surprise bills don’t arise.

Still, Essentia supports the law’s consumer protections, including the requirement to notify patients if Essentia isn’t in their provider network. “We’re very supportive of this provision of the No Surprises Act,” Farrell said.

Next year, under the law health providers will be required to provide estimated out-of-pocket costs patients would incur for care. Essentia has been providing estimates to patients for a number of years, Farrell said.

The complexity of medical care, in which five patients with the same condition could have five somewhat different treatments, makes cost transparency a challenge, he said. “We’ve started going down that journey, but we have a ways to go,” Farrell said.

Blue Cross Blue Shield of North Dakota also has a page on its website explaining consumer protections under the No Surprises Act.

Even though most of North Dakota’s medical providers are well integrated, surprise bills sometimes happen.

“From what I’ve seen, it’s fairly rare, but I can tell you it does happen,” said Jeff Ubben, vice president of compliance and regulatory affairs for Blue Cross Blue Shield of North Dakota.

The No Surprises Act will benefit consumers, he said. “We support transparency that I think this will add to the health care process,” Ubben said. “We don’t want to see our members receive surprise bills.”

North Dakota residents who have a surprise bill problem can contact the North Dakota Department of Insurance at insurance@nd.gov or by calling 701-328-2440.