Surprise! New Law Helps Patients Win Out-of-Network Billing Battles
I helped a patient leverage the No Surprises Act to beat back an overpriced surprise bill. You can use the templates I wrote to win your billing dispute, too.
The new Surprise Bill Act packs a powerful punch for consumers.
Just ask Shellie Schrattenholzer, who used the new law to compel a hospital to back off an unreasonable out-of-network medical bill.
Shellie heard me on the ZDoggMd show and reached out with what’s been a common problem for patients. On January 7 her specialist sent her for an ultrasound guided wrist injection to Providence St. Vincent Medical Center, near her home in Portland, Oregon. Her doctor told her it was the only place she could get the procedure.
The injection went well but she later got caught up in a billing fiasco. Shellie learned her procedure was out-of-network – meaning the hospital and insurer did not have agreed upon rates for the service. Her insurer denied coverage and she got stuck with a surprise bill for $1,490.90.
Out-of-network bills have afflicted millions of patients. They occurred in about 1 in 5 cases where privately insured patients went to the emergency room, had elective surgery or gave birth, according to a 2021 federal government report. The bills averaged between $750 and $2,600, the report said.
Because there are no contracted rates, out-of-network bills are often for exorbitant amounts.
Shellie reached out to me because she knew her bill was overpriced. But she had run out of appeals with her insurance company and was getting nowhere with the hospital billing department. The hospital was about to send her to collections.
Not so fast!
I explained to Shellie that the No Surprises Act went into effect at the beginning of this year, just days before her procedure. The new law bans surprise bills after emergency care and when patients go to out-of-network providers at in-network hospitals. It also requires health insurers and medical providers to resolve their disputes rather than send surprise bills to patients.
There are many particulars and caveats to the No Surprises Act. It doesn’t always apply and you can learn more in this issue brief. But to sum it up – it offers many new protections to patients.
I didn’t particularly care about the nuances of the No Surprises Act when it came to Shellie’s case. I was more interested in how it could be leveraged to get her a fair price.
Here’s are two of my favorite parts of the new law: Patients can now call a federal hotline for advice and they can file complaints about surprise bills. I love it! That’s the kind of power patients need on their side when they’re trying to convince billing departments to give them a fair deal.
Shellie and I discussed the No Surprises Act and she purchased and read my book, “Never Pay the First Bill: And Other Ways to Fight the Health Care System and Win.” Patients need to get educated so they understand how to navigate these perils of our health care system. My book and my Never Pay Pathway health literacy videos provide a sound foundation.
Getting educated motivated Shellie. The health care system is not set up to provide what’s in the best interest of patients, even those with insurance, Shellie said. “Understanding that helped catalyze this energy to push back and fight,” she said.
Shellie and I devised a strategy. I called the hotline to ask about Shellie’s case and a real live person answered. That was unexpected and quite nice! The friendly representative said the No Surprises Act might indeed apply to Shellie’s case.
Then I drafted templates of emails she could adapt for her case and send to her hospital and insurance company, to motivate them to resolve the dispute fairly. The emails said:
Her surprise bill violates the No Surprises Act.
Her insurer and medical provider need to settle the problem without passing it on to her.
She called the No Surprises Act hotline to understand her rights (which Shellie did).
That she would file a complaint with the federal government if the hospital and insurer did not comply with the law.
That the hospital and insurer had 48 hours to resolve the problem, or else she would file a complaint.
I pasted the templates of the emails the bottom of this post. You can use them, too, if you get an unreasonable out-of-network medical bill.
I recommended to Shellie that she send the email to any “decision makers who can simply snap their fingers to get this resolved.” Then, follow up with phone calls to make sure they see the email, and also to make sure it gets escalated.
It took Shellie a lot of courage to execute the plan. She’s a nurse and her husband is a doctor in the community, so she felt nervous making waves. She worried that it might not work. She said she tends to be a rule follower, so pushing back felt out of character. At times she even blamed herself.
“Cold feet today!” she wrote me in one message. “I know I should have checked to see if the hospital was out of network before proceeding…”
I’ve said this before: Courage is the secret ingredient for fighting unfair medical bills. Shellie’s husband sent her a picture of a lioness, which she said she has staring at her on her computer. “I’m channeling this lioness,” she told me.
It took guts but she stepped out of her comfort zone. Shellie adapted my emails and then sent them to her insurer and the hospital CEO, CFO and others. “I’m smiling because I can’t even believe I did it,” she told me afterward. “I really had to calm myself down after I did that.”
The next day she got an apologetic call from a manager in the hospital billing department. The manager told her that her email had “rattled some cages” up high. The people on the front lines in the billing department had not been updated about the provisions of the No Surprises Act, she said the manager told her. “They were not complying with the law,” Shellie said.
The hospital reduced her bill to $178, which she paid on the spot.
Shellie offered to waive her HIPAA privacy rights so Providence could talk to me about the case. The hospital sent a general statement. “Providence believes that no patient should be caught in the middle of coverage disputes or subject to surprise medical bills,” the statement said.
This is great news for Shellie – a real victory! But about 100 million Americans are burdened by medical debt, according to a recent Kaiser Family Foundation survey. Shellie felt struck by the fact that she, as an educated and privileged person, felt intimidated by the health care system. What about all those people who were unable to navigate the system and push back and now have bills in collections? “It feels so unjust,” she said.
Shellie said the experience changed the way she views the health care system, and she’s trying to get the word out to others. “I realized how much power we actually do have as consumers,” she said, “and how much we really don’t know about that power.”
We need more health care consumers to understand how much power they have and how to use it. Empowering consumers is my mission with Allen Health Academy and my new Never Pay Pathway health literacy videos. Please, check out the videos and share them. Scholarships are available. We are building a movement here and would love for you to join us.
Here are the templates of the emails that I wrote for Shellie to send to her hospital and insurance company , citing the No Surprises Act. If you or your loved ones are getting hit with an out-of-network medical bill for services that occurred after January 1, 2022, you could adapt these templates for your own use. Let me know how they work for you and if I can help!
To Whom It May Concern:
I’m writing to inform you that I am disputing the [$X,XXX] bill you sent me for services I received at your hospital on [Date after January 1, 2022]. Do not send my bill to collections, because I am disputing it.
Your bill is a violation of the federal No Surprises Act, which went into effect on January 1 of this year.
I have insurance. I cannot help that my doctor sent me to an out-of-network hospital for these services. Thankfully, Congress passed the No Surprises Act to protect consumers like me who find themselves in such circumstances through no fault of their own.
Under the No Surprises Act, you and my insurance company need to come to an agreement for the services provided, so you can be paid at an in-network rate. It is not acceptable for you to simply send me a surprise bill for the portion my insurance company refused to pay.
I just inquired with the No Surprise Act hotline (800-985-3059), where patients call to understand their rights about the new law. They said the law would apply to my situation, and they gave me the information I need to file a complaint against you if this matter is not immediately resolved. The website is https://www.cms.gov/nosurprises/consumers and I will complain to protect my rights.
I have made a similar notification to my insurance company, to inform them that they are also violating the No Surprises Act by failing to come to terms with you for this medical bill. I need you to comply with federal law and come to terms with them.
I will give you 48 hours to assure me that you will work with my insurance company to come to a resolution and stop pursuing me for this unjustified medical bill. If I do not hear from you, I will file my complaint.
Insurance company email:
Dear [INSURANCE COMPANY],
I’m writing to inform you that your denial of payment for my [procedure or treatment] at [hospital or doctor] is a violation of the federal No Surprises Act, which went into effect on January 1 of this year.
I cannot help that my doctor sent me to an out-of-network hospital for these services. Thankfully, Congress passed the No Surprises Act to protect consumers like me who find themselves in such circumstances through no fault of their own.
Under the No Surprises Act, you and the hospital need to come to an agreement for the services provided at an in-network rate. It is not acceptable for you to pay nothing and then leave me with a balance bill from the hospital.
I just inquired with the No Surprise Act hotline (800-985-3059), where patients call to understand their rights about the law. They said the law would apply to my situation, and they gave me the information I need to file a complaint against you if this matter is not immediately resolved. The website is https://www.cms.gov/nosurprises/consumers and I will complain to protect my rights.
Furthermore, the Health Insurance Portability and Accountability Act of 1996, the federal law better known as HIPAA, gives me the right to my Private Health Information, and that includes records related to claims adjudication, medical management and other records that are used to make decisions about me. I am also making a formal request for you to immediately provide this information so I can understand how you came to your decision to deny payment for this medically necessary care that I received.
It’s a violation of HIPAA for you to withhold this information. See here for more information: https://www.hhs.gov/hipaa/for-professionals/privacy/guidance/access/index.html. If you do not comply with my HIPAA rights, you will leave me no option but to file a complaint against you with the Office for Civil Rights.
This is a timely matter, because the [medical provider] is threatening to send me to collections because of your denial of payment. So I request that you provide me with this information in the next 48 hours. You should have these records in electronic form, so please email them to me at [email address]. They should also be easy for you to access, so there should be no charge for your compliance with this federal law.
Because this is timely, I am giving you a 48 hour deadline to contact the hospital so that you can come to an agreement about this bill. Federal law protects me from balance billing due to the provision of out-of-network care. I need you to comply with it.
Please let me know if you use the templates and how they work out for you. I look forward to sharing your Victory Story, so others can be informed and inspired by YOU!