With the notable exception of ground ambulance transport, it is prohibited for providers to bill customers for more than the in-network cost-sharing owed under their insurance as of January 1, 2022 in almost all circumstances where surprise out-of-network expenses emerge. When determining patient cost-sharing, health plans must treat certain out-of-network treatments as if they were in-network. The bill also establishes a new final-offer arbitration mechanism to determine how much out-of-network providers must be paid by insurers. If an out-of-network provider is unhappy with a health plan's payment, he or she might request arbitration. The arbitrator must choose between each party's final proposals, taking into account a variety of considerations such as the health plan's previous median in-network pricing for identical services.

Patients lack significant choice of provider for certain treatments, which is the core market failure that has resulted in the surprise billing problem. Patients may be forced to use an out-of-network facility or be treated by out-of-network doctors in an emergency. Patients often choose their facility and primary physician for elective care, but not their anesthesiologist, assistant surgeon, or other auxiliary provider; nevertheless, these ancillary professionals have separate contracts with insurance from the facilities where they work (and typically separately from the principal physician). As a result, regardless of their network status, emergency and ancillary physicians are guaranteed a consistent supply of patients, offering an out-of-network billing alternative unavailable to specialties that rely on in-network patient volume.

The regulation prohibits providers from exploiting leverage obtained from the capacity to surprise bill to collect exorbitant rates, addressing this market problem. In the case of services provided at in-network facilities, policymakers could have stopped there, allowing payment to be determined through negotiations between payers, facilities, and clinicians. Out-of-network emergency services and air ambulance services, on the other hand, require some sort of price support to avoid surprise out-of-network billing because these providers are required to treat any patient regardless of ability to pay and thus have no other leverage to negotiate with payers. The law's arbitration mechanism serves in this capacity. #shorts #medicaldebt #credithacks #nosurprises #medicalbilling #medical #debt

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About Limitless Culture and Mike Meza:
Hi, I'm Mike. I established Limitless Culture with a singular objective, to improve creditworthiness and provide credit education for regular, everyday people with fun and engaging content, DIY products, and (for some because no everyone needs it) monthly credit repair services for people with specialty disputing needs. I want to empower working-class people and their families to be able to take control of their credit files the right way.

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