Surprise Bills and Cancer Care

You pick the oncologist. You do not pick the pathologist who reads the biopsy, the anesthesiologist for the port placement, or the radiologist reading the staging CT.

Those are exactly the specialties that end up out of network inside an in-network hospital. Congress noticed. The No Surprises Act, effective for plan years beginning January 1, 2022, took most of that risk off patients, but the protection is uneven. Knowing where it holds and where it stops is the difference between paying a bill and disputing it.

CMS describes protection in three settings:

1. Emergency room care, including out-of-network charges.
2. Non-emergency care connected to a visit to an in-network hospital, hospital outpatient department, or ambulatory surgical center.
3. Air ambulance services.

Under 45 CFR 149.410, a nonparticipating emergency facility or provider must not bill you, and must not hold you liable, for any amount above your normal cost-sharing. Your deductible and coinsurance still apply. The gap between what your plan paid and what the provider wanted does not.

Notice what is missing from that list. Ground ambulance is not among the three protected categories.

Here is the part that pays off if you read your paperwork.

An out-of-network provider at an in-network facility can sometimes ask you to sign a notice and consent form giving up these protections. For a long list of services, that request is not allowed at all. Under 45 CFR 149.420, these can never be waived:

• Emergency medicine
• Anesthesiology
• Pathology
• Radiology and diagnostic imaging
• Neonatology
• Assistant surgeons
• Hospitalists
• Intensivists
• Laboratory and diagnostic testing
• Any service from a nonparticipating provider when no participating provider at that facility can furnish it

Read that list against a cancer workup. Biopsy pathology, staging scans, port placement anesthesia, tumor marker labs. The categories that generate the most surprise bills in oncology are the ones the rule places off limits.

The rule also protects anything arising from unforeseen, urgent medical needs that come up while care is being given.

Where notice and consent is permitted, the deadlines are specific.

If your appointment is scheduled at least 72 hours ahead, the notice must reach you no later than 72 hours before the service. If the appointment is made inside that 72-hour window, notice must come the day the appointment is scheduled, and at least 3 hours before the service.

So if someone hands you a consent form on a clipboard as you are being wheeled toward a procedure, the timing rule was not met. Take a photo of the form and the timestamp.

A separate set of rules applies, and it is stronger than most people realize.

Providers must give you a good faith estimate of what your care will cost, either when you schedule ahead or when you ask for one.

If the final bill comes in high, you can use patient-provider dispute resolution. Under 45 CFR 149.620, you are eligible when total billed charges are at least $400 more than the expected charges on the good faith estimate. You must submit your dispute notice postmarked within 120 calendar days of receiving that initial bill. An administrative fee applies.

A selected dispute resolution entity then decides. If the provider produces credible documentation justifying the difference, the entity picks the lesser of the billed charge or the median amount plans pay for the same service in your area. If the provider cannot justify it, the payment is set at the estimated amount.

Two things follow from this. Ask for the good faith estimate in writing before treatment, and keep it. Without it, there is nothing to measure the bill against.

• Do not pay it yet. Match the bill against your Explanation of Benefits. NCI notes that it is your right to question a bill with the doctor or the insurance company.
• Identify who sent it. A bill from a pathology group or anesthesia group after in-network hospital care is the classic protected scenario.
• Look for a consent form you signed. If the service is on the ancillary list above, the consent was not valid for it.
• Call the No Surprises Help Desk at 1-800-985-3059, available seven days a week, with support in Spanish, French, Arabic, Russian, Nepali, and hundreds of other languages.
• Ask the hospital for its financial assistance policy. Under 26 CFR 1.501(r)-4, nonprofit hospitals must post the policy, an application form, and a plain language summary on a website and provide paper copies. The policy must state all free and discounted care available, the eligibility criteria, how to apply, and what collection actions the hospital may take.

Be clear-eyed about the gaps, because they show up in cancer care.

Ground ambulance transport between facilities is not in the protected list. Neither is care you knowingly seek from an out-of-network provider at an out-of-network facility, such as a second opinion at a distant center. A bill that is high but correctly in network is not a surprise bill; that is a benefit design problem, and the answer there is the hospital's financial assistance policy or an appeal, not this law.

• Is this provider in network with my plan, and were they on the date of service?
• Was this billed as an emergency service, and under which place of service code?
• Did I sign a notice and consent form, and can I have a copy with the date and time?
• For self-pay: can I have the good faith estimate that was issued before this service?
• Is there a hold I can request on collections while a dispute is open?

• https://www.cms.gov/nosurprises
• https://www.cms.gov/nosurprises/consumers
• https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-B/part-149/subpart-E/section-149.410
• https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-B/part-149/subpart-E/section-149.420
• https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-B/part-149/subpart-G/section-149.620
• https://www.ecfr.gov/current/title-26/chapter-I/subchapter-A/part-1/section-1.501(r)-4
• https://www.cancer.gov/about-cancer/managing-care/track-care-costs