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Surprise Medical Bills and Personal Injury Claims

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Surprise Medical Bills and Personal Injury Claims

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Any personal injury claim will involve medical bills to some degree, and helping to resolve those bills out of the proceeds of a personal injury settlement, arbitration award, or trial verdict is an essential service that a personal injury lawyer can provide for clients.   The whole goal of the personal injury process is to compensate the claimant for the “damages” they sustained as a result of their injuries, and charges for medical care are typically a major element in those damages. Unfortunately, some medical care can result in unexpected, surprise medical bills that the claimants and their lawyers have to find ways to resolve. Fortunately, recent changes in federal law will help protect against these unexpected (and sometimes huge) surprise charges. 

Where Do Surprise Medical Bills Come From? 

As anyone who has had to negotiate the complexities of health insurance coverage in the United States knows, the question of, “What does my health insurance pay for?” can be extraordinarily complicated. Most health insurance plans depend upon primary care physicians contracted with the health insurer to act as “gatekeepers” to decide when patients need additional care and more specialized care, referring the patients to other specialists and providers who provide that care. “In-plan” medical providers — typically those who have contracted with the insurers to provide particular services for specific charges — will usually have their charges be covered either completely or at a greater rate than “out-of-plan” providers, for whose bills the health insurer may pay a lesser amount or even not cover them at all. So, when we need that specialized or additional care, we always look first to the in-plan providers who are almost invariably going to cost us much less out of pocket. 

Unfortunately, someone who has sustained a serious injury in a motor vehicle accident or other personal injury incident isn’t usually going to have the time or ability to seek a referral to an in-plan medical facility or doctor — an ambulance is going to transport them to a (hopefully) nearby facility where they can get rapid care for their injuries. Or, if their injuries are life-threatening, they may be transported by “life flight” helicopter service to an available trauma center. Whether or not these facilities contract with the injury victim’s health insurance providers is often just a roll of the dice. If they are not contracted to provide service for a specific compensated rate, and if the health insurance does not fully cover the facility’s billed rate, the medical provider will often bill the patient for the difference — often a vast difference — between the full bill and what the health insurer may pay. This practice is referred to as “balance billing” — charging the patient directly for the balance between the health insurance payment and what the provider’s full charges may total. 

In other situations, people who have experienced personal injuries may need follow-up care on an urgent but not emergency basis. If these individuals are either uninsured or prefer to pay out of pocket, it can be complicated to get accurate charge estimates on a prompt basis before receiving this care, resulting in surprise medical bills that may be much greater than anticipated. 

What Are the New Protections Against Surprise Medical Bills? 

Congress passed legislation (H.R. 133), referred to as the “No Surprises Act,” that went into effect on January 1, 2022. This legislation provides protections for anyone with employer-sponsored health insurance or with individually-purchased health plans and individuals who are uninsured or who are choosing to pay out of pocket. There are two main points of protection: 

Medical providers must furnish uninsured individuals and self-paying individuals with good faith estimates of the charges for services being sought within one to three business days. Although this may not directly help people with personal injuries that need immediate care, it may be beneficial for those who are uninsured or self-paying and need to seek follow-up medical care. If a bill exceeds the estimated amount by $400 or more, the law provides a process for disputing the charges.

For typical personal injury claimants, the significant protection is against “balance billing” practices for services provided by out-of-plan emergency rooms and doctors. One recent report by the U.S. Department of Health and Human Services found that 1 in 5 emergency room visits for insured patients resulted in surprise balance billings to the patient averaging $750 to $2500 per visit. Instances with very severe injuries or requiring air ambulance transport can result in balance billings of tens or even hundreds of thousands of dollars to the patient. The No Surprises Act also bans out-of-network coinsurance and copayments for most emergency services and most out-of-network balance bills for services provided by an out-of-network provider — such as a radiology service — during the course of care at an in-network facility.

Other State and Federal Laws Against Balance Billing 

There are already protections against balance billings for federally-sponsored health insurance coverages, including: 

  • Medicare 
  • Medicaid (Medi-Cal in California) 
  • Veterans Health Services 
  • Indian Health Servies 
  • Tricare 

Some states have specific laws that ban or limit balance billing practices. In these states, the local protections are not pre-empted by the No Surprises Act provisions — the new federal law merely provides minimum protection levels. 

View this video that describes some of the essential protections of the No Surprises Act:  

Personal Injury Lawyers in Sacramento

Hello, my name is Ed Smith, and I’m a Sacramento Personal Injury Lawyer. Experienced personal injury lawyers understand that securing compensation for their client’s injuries by way of settlement, award, or verdict is only one part of their services. Helping make sure that medical provider liens and charges are resolved to fairly benefit the client is also an essential service. Understanding how state and federal laws such as the No Surprises Act can be used to their client’s advantage is crucial. If you or a loved one have been seriously injured in a motor vehicle accident or other personal injury incidents, especially one where you feel you have received unexpectedly large medical provider bills, please contact us for free, friendly advice at (916) 921-6400 or (800) 404-5400. You can also reach out to us through our online contact form.       

Check out the case results our injury attorneys have obtained on our past verdicts and settlements page .a

Photo by jarmoluk from Pixabay     

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