civilservant

It just means you have the right to ask. He has the right to say no - and then you either accept that, or use a different GE. You'll probably find either he, or the facility, has a contract with the Anesthesiologist and they either can't (contractually) or won't go looking for one that's in your network.

Healthcare really is a mess. It's a web of contracts, all set up for the benefit of the providers and not for the benefits of the patients.

Steerpike

Update on this. Apparently this new Federal Bill was modeled after 'AB-72', a California law that also bans 'Surprise billing' and has been in effect in CA since 2017. From what I'm reading so far, the new Federal law only applies when there is no competing state law, so in my case, CA's AB-72 takes precedence. There is a new law in the works, not yet passed as far as I can tell, called AB-510 in CA that attempts to update CA's AB-72 to the new Federal standard, since there are some improved provisions in the Federal law not present in CA's AB-72. But AB-510 has not yet passed as far as I can tell, so I'm CURRENTLY stuck being regulated by CA's AB-72, and NOT the new Federal law. Any opinions on this welcome! This page is what I'm reading to suggest that AB-510 is not in force - https://legiscan.com/CA/bill/AB510/2021 .

The new Federal law specifically excludes exceptions for Anesthesiologists and Pathologists (and others), and specifically says that you cannot make an exception when there is no 'in network' alternative available at the facility. These provisions would, I believe, specifically protect me but - this does not seem to be in the CA AB-72.

I'm going to do a deeper read of what CA's AB-72 does cover.

In the meantime - I called the Anesthesiologist's billing department and got a quote for the service. Based on a CPT code of 45385, and an estimated duration of 45 minutes, they said the billed amount would be $1,992. That's not the 'negotiated rate' or the 'max allowed' rate, just "what they would bill". But - I then asked about the 'cash price' for the service (aka 'self-pay' amount) and he said it was $240 !!!! He said this would not apply if I were in a PPO that covered out of network charges, but since I'm in an HMO which doesn't cover out-of-network, I would be eligible for the self-pay amount of $240. His advice was to play out the entire insurance process first, and if all else fails, request the self-pay amount.

EDIT TO ADD: I just read the details of AB-72, which may be the governing law in my case, being a resident of CA. It contains the following:
""... the bill would make an exception from this prohibition if the enrollee or insured provides written consent that satisfies specified criteria."
...
"(1) At least 24 hours in advance of care, the enrollee shall consent in writing to receive services from the identified noncontracting individual health professional.
(2) The consent shall be obtained by the noncontracting individual health professional in a document that is separate from the document used to obtain the consent for any other part of the care or procedure. The consent shall not be obtained by the facility or any representative of the facility. The consent shall not be obtained at the time of admission or at any time when the enrollee is being prepared for surgery or any other procedure."
(3) At the time consent is provided, the noncontracting individual health professional shall give the enrollee a written estimate of the enrollee’s total out-of-pocket cost of care. The written estimate shall be based on the professional’s billed charges for the service to be provided (...).""

So my interpretation of this is - I have to give written consent to be billed for outside services. That written consent has to be obtained by the Anesthesiologist (or Pathologist), NOT the facility. The written consent must include a written estimate of the charges.

The 'disclosure' letter I pasted above, where they say I may be billed by the Pathologist or Anesthesiologist, does not seem to come even close to these requirements - no estimate provided, and not provided by the Anesthesiologist / Pathologist. So I THINK I'm in the clear.

Steerpike

Further to my post above, I'm now of the opinion that I AM covered by the new Federal law, even though CA's AB-72 provides similar protections. I'm basing this on this page (originally posted by ss120396 above) - https://www.cms.gov/newsroom/fact-sh...-medical-bills . It has a section as follows:
"What if my state has a surprise billing law?

The No Surprises Act supplements state surprise billing laws; it does not supplant them. The No Surprises Act instead creates a “floor” for consumer protections against surprise bills from out-of-network providers and related higher cost-sharing responsibility for patients. So as a general matter, as long as a state’s surprise billing law provides at least the same level of consumer protections against surprise bills and higher cost-sharing as does the No Surprises Act and its implementing regulations, the state law generally will apply."

and this page - https://www.brookings.edu/blog/usc-b...es-act/#cancel
has this to say:
"Many states have existing laws regulating surprise out-of-network billing. For the most part, the new federal law will simply supersede state laws. ..."

So I think I'm in pretty good shape.

Giantaxe

You should be. And thanks for posting all that valuable information. Otoh, if they do bill you for $$$ more than they legally are allowed, you are going to have to fight them. I had a situation with an urgent care bill where they clearly billed me for a service they didn't provide. My refusal to pay, along with an explanation for it, merely led to the unpaid portion of the bill being sent to a collections company. I did eventually manage to convince that company that they couldn't legally collect on the bill, but what a pita it was to get that far...