Ep 35 Healthcare Laws That Protect Patients

Why Those Forms Feel Sketchy

Dr. Johnston 0:01

This is Doctor Patient, a podcast that examines all the aspects of the patient-provider relationship. I'm your host, Heather Johnston, MD, a real-life doctor and patient. About once a year, in many of the doctor's offices I go to, they'll ask me to sign a bunch of forms, explained as privacy and financial forms. About 10 years ago, this consisted of someone handing over a laminated copy of two and three-page long, sort of legal eased documents that we all just signed without reading, because you couldn't read them anyway if you forgot your readers at home like I do. Then for a while, they stopped handing the physical forms over but explained a few sentences about each form and asked me to sign on an electronic signature pad on the desk. Nowadays, they just slide the signature pad over and say things like, sign here for your privacy information. Same as before, I sign without reading any of it, but it irks me that they don't even offer to explain what I'm signing anymore. For some ludicrous reason, I felt better getting to hold the laminated physical form for five seconds, even though, again, I wasn't doing anything with it anyway. Point being, the forms you're signing are related to federal and sometimes state health laws that you probably don't know much about, and you may not know what you're signing or why. It's not like you really have a choice. Most places require that you sign their forms or they won't treat you. But recently, while I was sitting in a waiting room mulling this over, it occurred to me that I don't really know that much about all of the healthcare laws that protect me and you as patients. So of course, I did what I do best and took a deep dive into the topic. And now I'm ready to share a lot of what I learned with you. I say a lot instead of everything because you would not like me very much anymore if I shared all of it. It's a little dry of a topic, but it's about your basic rights as a patient in today's healthcare system. So super important that we review all this.

HIPAA Privacy Plus Record Access

Dr. Johnston 2:05

I want to start with the one that most of you have probably heard of, HIPAA, the Health Insurance Portability and Accountability Act, passed in 1996. I touched on pieces of this in the episode I did on healthcare paperwork, but I want to go a little deeper here because HIPAA is really doing two different jobs. The first part, which most people know about, is privacy. HIPAA sets rules for who can see your health information, and it requires your providers to keep those records secure so that they actually remain private. Those are called the privacy rule and the security rule, respectively. But the other thing that HIPAA does, which is less well known, is that it gives you a right to get a copy of your own medical records. This is called the right of access. Under HIPAA, you can request your records from any provider or hospital, and they generally have to give them to you within 30 days, and in most cases, they can only charge you a very limited, reasonable fee for that, not whatever they feel like charging. This applies to all of your records, which it did not used to include. So not just test results and appointments, but the actual notes that your provider wrote, your radiology images, not just the reports, surgical notes, billing records, and nearly everything in your chart. These days a lot of offices and hospitals can see records from other places online over shared EMR or electronic medical record systems. But just in case that doesn't work for you or them, or if you want an actual copy of all of your records, it's good to know that you have the legal right to request your own complete file, either on paper or electronically. It's your data. I'll add here that my personal practice is to go into my own EMR and download anything of serious significance, whether it's test results, doctor's notes, etc., and then I keep those in a file on my computer. It's probably, I don't know, overkill and maybe irrational, but I worry that someday they won't be there anymore. Now, HIPAA has had some real developments lately that are worth knowing about. HIPAA's security rule, the part about how your electronic health data has to be protected from cyber attacks and breaches, is currently in the middle of a big proposed overhaul. HHS, or the Health and Human Services Department, proposed a rule at the end of 24 that would require much stricter cybersecurity practices from every hospital and doctor's office. Things like mandatory encryption or multifactor authentication. As of the time when I'm writing this, that rule has not yet been finalized. It's been sitting in a proposed form for over a year, and hospital groups have been pushing back hard on the cost that they will incur to comply with the new rules. So keep an eye on that one because if and when it finalizes, it'll probably be an upgrade to how your data has to be protected. Though I wonder if it'll make it just a little harder to get at it. I don't know about you, but I spend my days like doing multi-factor authentication all day, and sometimes it gets tricky.

Cybersecurity Updates Under HIPAA

Dr. Johnston 5:17

Let's move to a law that is the most important one for anyone who's ever walked into an emergency room. It's called Mtala, short for the Emergency Medical Treatment and Labor Act from 1986. If you show up at any hospital that accepts Medicare and has an emergency room, they have to screen you and stabilize you if you have an emergency medical condition, regardless of your ability to pay, regardless of your insurance status, regardless of your immigration status. In the U.S., this applies to the vast majority of ERs and does not apply for places like inpatient-only facilities or private niche type health centers or VA and military hospitals, although those have their own federal requirement to treat all patients. The ERs can't even ask you about your insurance or your ability to pay if you're having an emergency before they provide that screening and stabilization. Unless they deem your problem not an emergency, which they're fully allowed to do. Actually, that's literally their job. So unless they do that, they can't turn you away and they can't transfer you to another facility just to avoid the cost of treating you unless you're actually medically stable enough for that transfer and it's genuinely in your best interest. This is the law that means that an uninsured person having a heart attack gets treated in the ER just like anyone else. It's honestly one of the few places where our healthcare system says, no matter who you are or what you look like, we will help you. So this is a good one. I do want to say that mtala has become a little contentious over the last couple of years, specifically around pregnancy complications post-DOWS. Back in 22, the previous administration issued guidance saying that mtala's stabilization requirement could require abortion care in an emergency, even in states with abortion bans, because in some situations an abortion is literally the stabilizing treatment. But in May of 25, the current administration rescinded that specific guidance. What's important to understand is that it didn't repeal the Mtala law itself. The underlying law is unchanged, and ERs still have to stabilize patients with emergency conditions, but it removed the government's explicit written position that abortion counts as stabilizing care when medically necessary. And it's left a real gray zone for doctors and hospitals in states with strict abortion laws. There's a group of 22 state attorneys general who have since pushed back publicly saying hospitals are still obligated under MTAL, regardless of that guidance change. This is actively unsettled territory right now. And if you're pregnant and dealing with a medical emergency in a state with abortion restrictions, this is worth understanding because the legal landscape underneath it has become less clear, even though the core law hasn't changed.

ER Rights Under EMTALA

Dr. Johnston 8:32

In my opinion, this one law changed life for patients for the better more than any other. Most people think of it just as the law that created the insurance marketplace at healthcare.gov and expanded Medicaid, and it did both those things, but it also built in a long list of specific patient protections that exist independent of how you get your insurance. The big ones that are still fully in effect are, first, insurers cannot deny you coverage or charge you more because of a pre-existing condition. That includes things like a cancer history, diabetes, pregnancy, mental health diagnoses, or really anything. Second, there are no more lifetime or annual dollar caps on essential health benefits. Meaning, an insurer cannot say, we've paid out your million-dollar lifetime max, you're on your own now, which used to actually happen to people with expensive chronic illnesses. Third, young adults can stay on a parents' insurance plan now until 26. That's an important one because a lot of young adults these days are struggling with getting into the job market. And if they can't get a job with health insurance, you know, they could really be on their own. And this next one is the one that just went through the Supreme Court, which is that insurers have to cover a specific list of preventive services, things like cancer screenings, vaccines, contraception, statins for heart disease risk, with a zero cost sharing, meaning no copay, no deductible. That list is determined by a group called the U.S. Preventive Services Task Force, which I talked about in episode 30 on preventive health care. I'll also mention, because it's relevant to your wallet, even if it's not exactly a rights issue, that the pandemic era extra subsidies that made ACA marketplace-based insurance plans cheaper actually expired at the start of this year, 2026, because Congress failed to extend those subsidies. If you buy your own insurance through the marketplace, you may have seen your premium increase by as much as 50% this year. And that's why that happened. If you don't like it, write to your state representative and senator and let them know that. Another thing that the ACA did is give patients a formal right to appeal a denied insurance claim. This could happen as an internal appeal through your own health insurance company. And if that doesn't work, then an external review by an independent third party, someone not affiliated with your insurance company at all. A lot of people don't realize that that second step exists. If your insurer denies a claim and you disagree, you are not stuck simply accepting their first answer. And in almost all cases, I recommend that you do not accept it. Here's a scenario. Let's say your insurer denies coverage for an MRI that your doctor ordered, calling it medically not necessary. Step one is an internal appeal to the health insurance company directly, where you or your doctor, although it's usually the doctor in their office, submit additional clinical information and documentation directly to the health insurer asking them to reconsider. I've personally been through this first step successfully twice this year already. If they deny it again, step two is that external review where a truly independent medical reviewer, someone with no financial relationship to your insurance company, looks at the case and makes a binding decision. And as part of this law, insurers have to give you the instructions on how to actually appeal a denied claim at the time that they deny it. It's usually in small print towards the end or near the bottom of the denial letter. Another side tip is that if you're in an appeal process for denied coverage and having trouble, you can reach out to the Attorney General's office for your state. Almost all states have a healthcare division that offers consumer protections in the healthcare marketplace. I've put the phone number for the Illinois office in the show notes. Before I move off the ACA, I want to mention two lesser known. And by the way, see how big this law is? There's just so many things involved. Okay, I'm going to mention two lesser known but super important parts of this law. First is the Genetic Information Non-Discrimination Act called GENA from 2008, which makes it illegal for health insurers to use your genetic test results or your family history of a genetic condition to deny you coverage or raise your rates. This matters more than it used to because genetic testing has become so much more common with people either doing consumer DNA tests on like Ancestry.com or getting tested for BRCA type mutations because of a family history of breast cancer and other tests like that. Without this law, a positive genetic marker for a disease you don't even have yet could theoretically be used against you the way pre-existing conditions used to be. And I'll just stop for a sec to say here in the middle of this episode that it's sort of a sad state that all these laws had to be written in the first place. Oh, U.S. Healthcare. All right, lastly, as part of the ACA, there's the Patient Self-Determination Act from 1990, which requires hospitals, nursing homes, and other Medicare and Medicaid funded facilities to ask you on admission whether you have an advanced directive, a living will, or a healthcare power of attorney, and they have to document your wishes about your own care if you become unable to speak for yourself. It also requires them to give you information about your right to make those decisions in the first place, including the right to refuse treatment. I mentioned advanced directives and healthcare power of attorney and other forms in much more depth in episode 27 on healthcare paperwork, but I wanted to flag it here specifically as a federal patient right. Here's a scenario that shows why this matters. Say you're admitted for a planned surgery that has some real risk to it. Under this law, the hospital has to ask when you get there if you have an advanced directive, living will, etc. And if you say you don't have one, they're supposed to offer you information on how to create one right then and there before anything goes wrong. It's a small administrative moment, that one question at intake, but it exists because for decades, decisions about incapacitated patients were sometimes made by whoever happened to be in the room. A spouse, maybe a spouse that you're estranged from, a doctor, maybe a doctor that you don't know, a hospital ethics committee representative, whomever. And they had to do that without any documentation of what the patient themselves actually wanted. If you want to learn more about all of that other paperwork, head to episode 27. That's it for the giant expansive ACA.

ACA Protections And Fighting Denials

Dr. Johnston 15:39

Closely related to all of this is a broader legal idea of informed consent, which isn't one single federal law, so much as a core principle that runs through both some common laws and some specific state statutes, including where I am here in Illinois. The basic idea here is that before a doctor can perform a procedure or start a significant treatment, they have to tell you in terms you can actually understand, that's actually sometimes where this goes wrong, what the treatment is, what the realistic risks and benefits are, and what your reasonable alternatives are, including the alternative of doing nothing at all. And you have to actually agree to it, not just have a form waved in front of you. This is why you sign a specific consent form before a surgery or procedure that's separate from all that other general intake paperwork, because that form represents an actual conversation that should have happened, not just a formality. My personal experience with the informed consent is that I'm asked to sign it at any point between the front door and when I'm about to be literally wheeled down the hallway. The form has to be reviewed by a person who's doing the procedure, so often some level of doctor. And if a doctor fails to go through the information with you and have you sign the consent form and something goes wrong that you weren't warned about, that can be the basis of a medical malpractice claim, separate entirely from whether the procedure itself was performed correctly. Here's a scenario. Say you consent to a hip replacement and you're told the general risks, infection, blood clots, that kind of standard list, but you're never told that this particular type of implant has a higher failure rate in patients your age. Information that your surgeon would have had and could have given you. If the implant fails, you may have a legitimate informed consent claim, independent again of whether the surgery itself was successful or not. The thing here isn't just did they do a good job, it's did I actually get to make an informed choice in the first place? That's informed consent.

Informed Consent And Real Choice

Dr. Johnston 17:45

Now let's talk about a piece of legislation that gets a little less airtime than HIPAA or the ACA, but it has quietly become one of the most consequential patient rights laws of the last decade. It is the 21st Century Cures Act, passed in 2016. And the piece of it that I want to focus on is something called information blocking. Before this law, it was not uncommon for hospitals and health systems to restrict patients from seeing their own clinical notes, test results, and records. Also, offices would sit on results for days, sometimes because they're waiting to have a conversation about the results with you first, but sometimes just because the system wasn't built for speed. The Cures Act, as it's called in short, made it illegal with only some narrow exceptions for a healthcare provider or a health IT company to block, delay, or interfere with a patient's access to their own electronic health information. This is the reason that many of you can now log into your patient portal and see a new lab or imaging results sometimes before your doctor has even called you about it. Here's an example of how this might play out. Say you get a concerning biopsy result back in your EMR on a Friday afternoon. Under the old system, that might sit in a queue until your doctor's office called you Monday or Tuesday or Wednesday, an agonizing weekend and days of not knowing. Today, in most systems, that result posts to your portal automatically, often the moment it's finalized. This can be good or bad for people. Some people love that immediacy, but sometimes this means that people are trying to read test results that they don't understand without any guidance from their provider. I've had a lot of calls from friends and family about this in the last couple of years. I have this test result, I don't understand what it means. Or you might get bad news by simply reading the test result yourself and not by getting an empathetic and explanatory call from your provider. I recently had an MRI for my hip and found out that I have a small tear in the joint, but then I couldn't get a hold of my orthopedic surgeon for days and days afterwards to talk about what that meant for me. So I had to just sit on that info and wait. The point is though, it's your legal right to have the access to your records. And if a provider is deliberately withholding your records from your portal without a valid clinical reason, you can actually file a complaint about it. So putting HIPAA and this 21st Century Cures Act together means that the right to get everything, including images and provider notes, is HIPAA. The reason it now shows up in your portal almost instantly is the Cures Act.

Cures Act And Instant Portal Results

Dr. Johnston 20:33

Let's move on now to the very fun topic of surprise medical bills, because many people have either experienced this or know someone that has. This is where the Nose Surprises Act comes in, which took effect uh just a few years ago in 22. Here's an example of how surprise billing could get you before this bill passed. You go to an in-network hospital for planned surgery. The surgeon is in network, the hospital is in network, everything looks great on paper, and then months later you get a bill for $1,200 from the anesthesiologist, who it turns out was out of network. Even though you have zero say in which anesthesiologist gets your case, and you have obviously no way to check their network status while you're under anesthesia. That's called a surprise bill. And before this law, it was completely legit and legal for that anesthesiologist or whoever it was, the radiologist reading your scan or an assistant surgeon to bill you directly for the difference between what your insurance paid and what they wanted to charge. The No Surprises Act made most of that illegal. There's one special scenario worth mentioning that this law involves, which is that if you receive emergency care, you can only be charged your normal in network cost sharing period, regardless of which hospital or provider treats you. But again, that's for an emergency. Not like I have a bad rash, I'm going to the emergency room. This is for emergencies like I'm bleeding and might die from it, my limb is cut off, I'm having a heart attack, things like that. For non-emergency care at a facility that's in network, if an out-of-network provider ends up involved without your explicit advanced consent, like the anesthesiologist in the example I gave, you also can't be billed beyond your normal in-network costs. Instead, the provider and the insurer have to hash out the rest of the payment between themselves through something called independent dispute resolution. But that doesn't matter to you because you're not part of that fight anymore. Lastly, there's something also involved in this law called a good faith estimate requirement. So if you're uninsured or paying cash for a scheduled procedure, the provider or facility has to give you a written estimate of the expected cost in advance. And if the final bill comes in more than $400 over that estimate, you can dispute it. I do want to note here that Illinois also has its own version of this very protection on the books. It's a state law called Public Act 1020901, which bans balance billing, as it's sometimes called in very similar situations, but just for state-regulated insurance plans. So Illinois residents, if you're on a state-regulated insurance plan, you get overlapping protection here, both from the federal No Surprises Act and from this state law, which matters because not every health plan is subject to federal rules. These state-regulated plans only follow their own rules, so both of these matter. If you think you've been wrongly billed in a similar scenario to what I've been describing in Illinois, you can contact the Illinois Department of Insurance's Consumer Health Line. And again, I'll put that number in the show

No Surprises Act And Cost Estimates

Dr. Johnston 23:56

notes. I want to switch for a minute and talk about mental health treatment for a moment because there are some rights in here that are very particular to just mental health care. The Mental Health Parity and Addiction Equity Act, these are all such mouthfuls, requires insurers generally to cover mental health and substance use treatment no more restrictively than they cover physical health treatment. Meaning, if your plan doesn't require prior authorization for a cardiology visit, it generally can't impose a prior authorization for a psychiatry visit either. In practice, the law has been chronically underenforced. That's the truth. Insurers have found many workarounds, things like narrowing their mental health networks and among other tricks. Regulators have tried to close a lot of these loopholes with a stronger final rule in 24, and we're still seeing how that plays out. Alright, I want to shift to a law that protects patients in a different way, not by giving you any specific personal right, but by punishing people who defraud the system that you rely on. It's called the False Claims Act, and I want to talk about it because it's actually in the news a lot. Oddly, it's a very old law. It dates back to the Civil War because it was originally aimed at contractors selling defective supplies to the Union Army. False claims, right? But today, it's one of the most powerful tools against health care fraud in the country. It makes it illegal to knowingly submit false claims for payment to Medicare or Medicaid, and it includes something called Qui TAM provisions, which let ordinary people, often employees inside of a hospital or clinic, file a lawsuit on the government's behalf if they discover fraud. And if the case succeeds, the whistleblower can personally receive a cut of the settlement. Why does this matter to you as a patient rather than just as a taxpayer? Because a lot of the fraud that this law catches directly involves patients. Things like doctors billing for procedures that were never performed, patients being billed for a more expensive service than what they actually got, nursing homes billing for care they never provided. Or, and this is a big current category, patients receiving medically unnecessary tests or procedures purely to generate billable claims. This law had its biggest year ever recently, in fiscal year 25, when the Department of Justice recovered over $5.7 billion specifically just from healthcare fraud and largely, almost entirely from Medicare Advantage plan providers. So if you ever notice something that looks like billing fraud, being charged for a visit that didn't happen, a service you never received showing up in your insurance statement, that instinct is worth taking seriously because it does happen, and there's attorneys who specialize in exactly these cases.

Mental Health Parity And Fraud Enforcement

Dr. Johnston 26:56

I'm going to pivot now to talk about laws in Illinois specifically, since a handful of these protections either only exist at the state level or work alongside the federal ones. If you don't live in Illinois, you can either listen along because your state may have similar laws, or you can skip to the last few minutes where I wrap up. The centerpiece here is the Medical Patient Rights Act. This law lays out a baseline bill of rights for anyone receiving care in an Illinois healthcare facility. It's pretty wide-ranging. A few of the pieces I think matter most in real life. First, every hospital has to allow you to designate visitors of your choosing, and that includes unmarried partners, chosen family, whomever you say, really, because hospitals cannot restrict visitation to only legally recognized relatives. It also protects your privacy in a way that predates HIPAA and works alongside it. Providers can't disclose the nature of the services you receive to another person except in specific defined circumstances. And there's an explicit anti-discrimination provision in the law whereby hospitals can't treat you differently based on race, color, or national origin when that has nothing to do with your actual medical diagnosis or treatment. So if you feel like that's happened to you, hospitals are required to give you information on how to file a grievance, both internally and with the Illinois Department of Public Health or the Illinois Department of Human Rights. Here's an example that illustrates why the visitation piece matters more than people might think. Say you're in a same-sex relationship and are unmarried and your partner is hospitalized after an accident. Under this law, if your partner's designated you verbally or in writing as someone they want present, the hospital legally cannot bar you from the room simply because you're not next of kin in the traditional legal sense. This next Illinois law is a little nitpicky, but it caught my eye when I was reading. Illinois law HB 1137 from 23 addresses what happens when a healthcare provider or facility alters your medical record after the fact. This law requires that if a provider changes something in your chart, they now have to notify you in writing within three business days of that alteration. And if you request an electronic copy of your medical record, they have to provide you both the original and the changed version within seven calendar days, or if it's a facility that accepts Medicaid, within four business days. Here's why the law exists, and it's a little unsettling to explain. In medical malpractice cases, one of the recurring problems has historically been records getting quietly modified after an adverse event, sometimes to correct a genuine error, but sometimes to obscure what actually happened before an investigation or a lawsuit. This law builds in a real deterrent because if they blow the deadlines of giving you all the records you're asking for, the law assumes the worst about their motive unless they can prove otherwise. That's a significant legal consequence built into a fairly quiet technical statute, and it exists specifically to protect the integrity of your medical record as a legal document, not just as a clinical one. Moving on, Illinois has been unusually active on the insurance side of things over the past couple of years. In 24, Governor Pritzker designed what's been branded the Healthcare Protection Act, alongside a broader package, sometimes called the Patients Over Profits Reforms. I love the name of that, which took effect at the start of 25. Two pieces of this stood out to me. First, Illinois became the first state in the country to ban prior authorization requirements entirely for inpatient mental health care, both for adults and for children. That means if you or your child needs to be admitted for a mental health crisis, the insurance company cannot make you wait for their permission first. The admission happens, then the paperwork follows. Second, that same package banned what's called step therapy, sometimes nicknamed fail first, where an insurer requires you to try and fail on a cheaper medication before they'll approve the one your doctor actually recommended. So insurers in Illinois can no longer force that sequence of events. On top of this, effective January 1st of 25, Illinois's prior authorization reform act put hard deadlines on insurers for all other prior authorization decisions. Because in truth, I'm sure you've heard about prior authorizations in the news or from yourself or from people that you know, it can be a nightmare just waiting for your insurance company to decide what you're allowed to do and not allowed to do. So now in Illinois, urgent requests have to be decided within 48 hours, which honestly, in some cases, is not even really fast enough. And an urgent medication requests have to be approved within 24 hours. Approvals for chronic condition medications or treatment now have to last a full 12 months before you need to be reauthorized again, instead of the shorter windows insurers used to impose. And health insurance companies are now required to publish their prior authorization requirements publicly on their websites and use more standardized forms so your doctor's office isn't stuck guessing at a different individualized process for every single insurance company. If you've ever waited on hold for days trying to get your doctor's office and your insurance company to agree on whether you can actually get a medication or a procedure, this law was specifically built for

Illinois Rights Prior Auth Debt Relief

Dr. Johnston 32:55

you. One more Illinois law I want to mention because it addresses something that might keep some people up at night: medical debt. As of January 1st, this year, 26, under a law called Public Act 1030648, medical debt can no longer appear on your credit report in Illinois at all. Consumer reporting agencies are prohibited from including medical debt or medical collection actions on an Illinois resident's credit report. In most cases, the law doesn't erase the debt. You still legally owe the money, and a provider can still send it to collections and technically still sue you over it in rare cases, but it no longer can harm your actual credit rating and credit score in Illinois. But another interesting part of this law is that in some cases, your debt may actually be automatically erased. This gets a little complicated, so I'm going to seriously summarize it. And if you want to know more, there will be a link in the show notes to read about it. The second separate law, Public Act 1030647, is also called the Medical Debt Relief Act. When you owe a hospital or medical center money and can't pay it in Illinois, that debt either sits in the hospital's accounts or they might sell that outstanding debt to a collections agency. But sometimes a national nonprofit group called Undue Medical Debt comes in and uses the state's money to go buy up those debt portfolios, either directly from a participating hospital or from a collection agency. And then instead of trying to collect on it the way a normal debt buyer would, it simply cancels the debt. Sounds too good to be true? Well, it only applies to people who are at or below 400% of the federal poverty level, or people whose debt is equal to or more than 5% of their annual household income. But wait, there's more. Oh my gosh, that just reminded me of the old Ginsu knife commercials. Sorry, for those of you my age, you'll get it. There's a ridiculous part to the whole process, which is that if you have big medical debt and if you meet these income thresholds, and if your hospital or medical center participates in this program, the debt forgiveness does not happen automatically, but you also can't request it. And because the undue medical debt nonprofit only scans for debt sometimes, yours might just get missed. Sound unbelievable? Yeah, I'm with you. Very last one. I want to mention hospital price transparency just briefly. Since 21, hospitals have been federally required to post their actual negotiated prices for common services online and at the physical location. In theory, this lets you shop around before a procedure, the way you might for any other big purchase. Although in reality, most people already have their in-network place that they stick with, and starting to shop around is a big time hassle, and often you don't know anyone at the other places you look at. Also, in practice, compliance with this law has been very spotty. The online files are often difficult to actually use, enforcement is inconsistent, but the Center for Medicaid and Medicare Services just finalized another round of tightened requirements this past November, requiring hospitals to post actual median and percentile prices instead of vague estimates. And there's supposedly better enforcement starting in April of this year 26. It's not perfect, and I wouldn't rely on it heavily yet. But for a planned non-emergency procedure, it's worth a quick online search of the hospital's name plus price transparency file before you commit, especially if you're uninsured, paying cash, or have a high deductible plan. This will help with both decision making and financial planning.

A Practical Checklist To Push Back

Dr. Johnston 37:13

What do you actually do with all of this information I just gave you? I don't expect you to memorize acronyms and statute numbers, but what I'd love for you to walk away with instead is a basic mental checklist of where to push back when something feels wrong. Knowing what rights you have as a patient empowers you to speak up when something isn't going according to these laws. If a medical bill has an unexpected out-of-network charge you never agreed to, that's the No Surprises Act. And in Illinois, you have that state law backing it up too. So call your insurer, cite the law, and ask for a corrected bill. If your insurance company denies a claim, remember that denial letter has to tell you about your right to an internal appeal and then an external review. Use both. Don't stop at the first no. If a hospital or clinic is slow walking releasing your medical records, you can call them and remind them that it might be information blocking under the Cures Act, and you can also file a complaint through the federal information blocking portal. If a hospital tries to limit who can visit you or a loved one based on something other than actual medical necessity or discriminates in your care, that might be against the Illinois Medical Patient Rights Act, and you can file a grievance with the hospital and with the Illinois Department of Public Health. If you're stuck waiting on a prior authorization, push back citing the Prior Authorization Reform Act directly by name. And if old medical debt is still dragging down your credit score here in Illinois, dispute it directly with the credit bureaus citing Illinois Public Act 1030648. None of these laws are perfect. And as you heard throughout this episode, some of them are going through some changes and updates as I speak. Healthcare law rarely holds still for long. But that's exactly why I think it's worth doing an episode like this every so often, because the version of what rights do I have that was true five years ago or honestly even two years ago may not be the version that's true today. My best advice is this. When something in your care feels unfair or off, don't just assume that's how it is or how it has to be. Sometimes there's an actual law behind that instinct, and increasingly, actual enforcement behind the law too. I'll drop links to all of these laws and a few relevant complaint portals and phone numbers in the show notes, so you have them on hand if you ever need them. But I hope that you don't. Thanks for listening today. Thanks for listening

Subscribe Guest Ideas Disclaimer

Dr. Johnston 39:52

today. To catch up on more episodes and to get new ones delivered directly to you, subscribe wherever you find your podcasts. Apple, Google, Spotify, iHeartRadio, and more. If you'd like to be a guest or have an idea for an episode, let me know at www.drpatientpodcast.com. That's doctorpatientpodcast.com. Here's the disclaimer. Even though I am a doctor, I'm not your doctor. These stories, my comments, and all discussion is purely reflection about what's working in the healthcare system and what isn't. Don't use any medical information that you hear in these episodes to diagnose or treat yourself. If you have a question about your health, get in touch with your doctor or local health clinic.