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Empowering Patients: What you Need to Know About the No Surprise Act

Young man looking at medical billThe No Surprise Act (NSA) is a federal law that protects consumers from unexpected, surprise, medical bills. There are multiple facets which affect each consumer differently:

  • Price Transparency requires all hospitals to provide a list of prices and services they offer to patients with medical codes or Current Procedural Terminology (CPT), description, and pricing. To help our patients better understand healthcare services, the cost of their care, and comparison shop between hospitals, additional information is available at www.wipricepoint.org.

  • Good Faith Estimates. This pertains to self-pay, uninsured patients only. Providers are required to give consumers a good faith estimate if care is scheduled at least 3 business days in advance. Estimates are always available upon request and must include descriptions, CPT codes, total pricing, and patient information. The estimate may be over the actual amount charged, but cannot be under more than $400. In the case of the latter, a patient may dispute with the facility. Examples of Good Faith Disputes.

  • Independent Dispute Resolution. This allows patients to dispute charges and patient responsibility from insurance processing. All disputes must include a written copy or screenshot of the original estimate. If a patient has reached out to their insurance company and facility without success, a complaint may be filed with Centers for Medicare & Medicaid Services (CMS).

  • Out-of-Network Protection for Emergent, Air Ambulance, and Convening Providers. This protects patients with insurance who seek care during an emergency and ensures in-network cost regardless of network status at the presenting facility. This also applies to Air Ambulance and Convening Providers. For example, a Convening Provider at DCMC would be a Radiologist; DCMC performs the Diagnostic Image (x-ray, MRI, CT, Ultrasound, etc), but the Radiologist, who is not DCMC staff, reads the test.

  • Continuing Care Patient Coverage. Most types of health insurance allow for 90 days of in-network coverage after your provider leaves the plan's network. This includes patients that:

    • Are undergoing treatment for a serious and complex illness

    • Are undergoing institutional or inpatient care

    • Are scheduled to get non-elective surgery

    • Are pregnant and undergoing treatment

    • Are terminally ill

The NSA does NOT apply to health insurance programs that already have surprise medical billing protections such as Medicare, Medicaid (BadgerCarePlus), Indian Health Services, Veterans Affairs Health Care or TRICARE. However, our Patient Financial Advocates are happy to assist all patients with questions about their billing.

How do I get an estimate on services?

Woman getting medical cost estimateDCMC's Cost Estimator allows consumers to make informed decisions about their healthcare in real time. It empowers a patient to compare and budget for services—elective or otherwise—or to seek financial aid from our Community Care program. For example; if a patient wants a procedure done and meets their deductible; they may want it done this year. Alternatively, a patient wants a procedure done, but their deductible is not close to being met; they may wait for the next year.

"We always advise patients these are only estimates," says DCMC Financial Advocate Lead Tiffaney Delwiche. "We each have different health histories that could affect an estimate. We also encourage patients to reach out to their insurance for coverage and check network and tier status, as these can affect an estimate as well."

Our charge master is available on our website, under Patient Financial Services Insurance & Estimates. The Cost Estimator is linked to our internal estimate tool with a majority of our services listed and maintained (non-schedule services may not be on this list). A patient will need to know some of their insurance benefits for an insured estimate.

If you are a patient who does not know your insurance information, would like to make sure you have a correct CPT code, are undecided on a procedure, or prefer to speak with someone to walk you through an estimate, please call Patient Financial Services department 920-746-3502 option 3 (Financial Advocates)

For help in Español, Français, عربي, русский, नेपाली, and 350 other languages contact Centers for Medicare & Medicaid Services: 1-800-985-3059.

Published 12/1/2023 6:00:00 AM
Tags: bill, news, no surprise act, patient financial services

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