Identify:
Identify where hospitals obstructed cooperation or violated federal laws.Use these points to negotiate bill reductions.
Fair Trade Practices (FTC Act Section 5a):
This rule prevents businesses from engaging in unfair or deceptive practices that affect commerce.
Financial Assistance Policies (ACA, IRS Section 501®):
Hospitals are required to clearly share information about their financial help programs with the public.
Hospital Pricing Transparency (ACA Section 2718E):
Every hospital in the U.S. must create and share a yearly list of their standard prices for services and items, including rates for specific treatment groups under the Social Security Act.
HIPAA (Health Insurance Portability and Accountability Act)
Protects patient privacy and ensures the confidentiality of health-related information, which can be crucial when disputing medical bills or handling sensitive data with healthcare providers.
No Surprises Act:
Protects consumers from unexpected medical bills for out-of-network emergency care. Patients can’t be charged extra by out-of-network doctors or hospitals. Instead, the health plan and the provider must agree on a fee or have an independent party decide it.
Price Transparency Rule (HHS 9915):
Hospitals must publicly share the actual prices paid for their services, known as the Amount Generally Billed (AGB). This includes discounted rates for major insurance companies like Blue Cross Blue Shield, United Healthcare, Cigna, and Aetna, as well as Medicare and cash prices.
(EMTALA): Emergency Medical Treatment and Labor Act
Obstruction of Cooperation: Some hospitals may violate EMTALA, which requires hospitals to provide emergency treatment to all patients, regardless of their insurance status or ability to pay. Refusal to treat or billing disputes over emergency services could be evidence of obstruction.
Fair Debt Collection:
Aims to stop abusive, misleading, and unfair debt collection practices.
Report Violations:
For more information or to report violations, you can contact CMS through their website. Additionally, contact our advocates for support or questions.
Standing Firm:
Standing firm against unfair billing practices can lead to successful outcomes, often without the hospital pursuing legal action due to the risk of a judge setting a lower payment amount.
Hospital Charitable Obligations (Nonprofit hospitals):
Nonprofit hospitals have certain charitable obligations due to their tax-exempt status under IRS Section 501(c)(3). If hospitals obstruct access to their financial assistance programs or mislead patients, they could violate these obligations.
Fair Credit Reporting Act (FCRA):
This law governs how medical debts are reported on credit reports. Hospitals or debt collectors could be in violation if they fail to properly report or misreport medical debts.
Patient Bill of Rights
:Some states have their own versions of a Patient Bill of Rights, and obstructing cooperation by failing to provide patients with information about their rights or their options for appeal could be another violation worth mentioning in negotiations.
Prompt Pay Discounts:
Some states have laws that require hospitals to offer discounts for patients who can pay their bills promptly. If hospitals fail to inform patients of these discounts or obstruct access to them, they could be violating state laws or engaging in deceptive practices. Be sure to ask about prompt pay discounts when negotiating bills.
Balance Billing Protection Laws (State-Level)
State Laws: Many states have specific laws protecting consumers from balance billing, which occurs when a patient is billed for the difference between what the insurance pays and what the provider charges.
Medical Debt Collection Reform Laws (State-Level)
State Laws: Some states have enacted laws to protect consumers from aggressive medical debt collection practices and provide additional consumer protections.
Patient Protection and Affordable Care Act (PPACA)
PPACA: Includes provisions beyond financial assistance, such as preventative services and protections for those with pre-existing conditions.
Consumer Financial Protection Bureau (CFPB) Regulations
CFPB: Provides guidance on medical debt collection and consumer protections related to financial practices.
Medicare Advantage & Part D Coverage Protections
Medicare Advantage: Provides additional protections and benefits not covered under standard Medicare.
Part D: Covers prescription drug costs and has specific rules about coverage and billing
Patient Financial Assistance Programs (State-Level)
State Programs: Some states offer additional financial assistance programs or subsidies for low-income patients, beyond federal regulations.
Healthcare Price Gouging Laws (State-Level)
Price Gouging Regulations: Laws that prevent price gouging in healthcare services, which can help protect consumers from exorbitant charges during emergencies.
Medically Necessary Services
Coverage for Medically Necessary Services: Laws or regulations ensuring that services deemed medically necessary are covered by insurance, which can help in disputing unexpected charges.
Insurance Appeals and Grievance Procedures
Appeals Process Overview:
Initial Denial Review: Examine the denial reason and gather documentation.Internal Appeals: Submit a formal appeal to the insurer with supporting documents and explanations.
External Review: If the internal appeal is denied, request an independent external review to assess the insurer’s decision.
Regulations:
Affordable Care Act (ACA): Requires insurers to provide an internal appeals process and access to external reviews.
Employee Retirement Income Security Act (ERISA): Mandates fair appeals processes for employer-sponsored plans.
State Regulations: May offer additional protections and requirements.
Key Steps for Consumers:
Understand Policy: Know your insurance policy’s terms and appeals process.
Gather Documentation: Collect and organize all relevant records and bills.
Submit Appeal: Write and submit a clear appeal, following the insurer’s guidelines.
Follow Up: Track the appeal’s progress and keep communication records.
Seek External Help: If needed, request an external review or consult with an advocate or legal professional.
Resources:
State Insurance Departments: Provide guidance and support.
Consumer Protection Agencies: Offer additional resources and assistance.
Legal Assistance: Consider consulting a health insurance lawyer for complex cases.
