Surprises come in all shapes and sizes…and in the latest coronavirus stimulus package passed and signed into law in late December, there is at least one medical-related surprise – and it’s a pleasant one.
Many goodies are included in this massive legislation, much of it related to jump-starting an economy adversely impacted by the COVID-19 pandemic. After two years of debate in Congress, one long-standing issue that has been elusive from legislative action has now become law – curbing surprise medical bills.
The End to Surprise Medical Billing
Also known as the ‘No Surprises Act’, consumers (patients) will no longer receive unexpected ‘balance bills’ when seeking ‘emergency’ care, such as air ambulance transportation, or when receiving ‘nonemergency’ care at an in-network hospital. A balance bill represents the difference between the provider’s charge and the allowed amount (negotiated between the insurance company and providers). This law will take effect in 2022.
In a survey released in early 2020, about 18 percent of emergency room visits resulted in at least one surprise bill. In the past few years, about 1-in-5 insured adults had an unexpected medical bill from an out-of-network provider.
Typical scenarios occur when patients are required to pay additional costs due to the contract between the network provider and a non-network provider who will not accept the insurer’s negotiated fee. Prior to the enactment of this new law, the non-network provider could legally bill unsuspecting patients their non-negotiated fee. When this law takes place, patients will pay only the deductibles, coinsurance and copayment amounts they would under the in-network terms of their insurance plans.
How Non-Network Providers Are Paid
Going forward, non-network providers will need to work out acceptable payments with the affected patient’s insurer. If the patient is uninsured, then all providers are considered out-of-network, and this will require the secretary of the Department of Health and Human Services to create a provider-patient resolution process for billing purposes.
Balance billing for air ambulatory transportation, a frequent and egregious practice, will not be allowed under the new law. A far more commonly-used service, ground ambulatory transportation, has not been addressed under this legislation. However, an advisory committee will be established to recommend how to solve payment for this service.
Can Patients Still be Balanced-Billed?
In nonemergency circumstances, physicians can balance-bill their patients for services, but to do so, they must obtain consent in advance of the medical procedure. As an example, a patient may want to seek care from a non-network physician, such as a surgeon. The surgeon will need to provide a cost estimate and get the patient to consent at least 72 hours before treatment. If the turnaround time is shorter than this, the patient must receive the consent information the day the appointment is made. Additionally, the estimate must be made in good faith.
Many types of physicians, however, may not be allowed to seek consent to balance-bill for their services. Among these include: anesthesiologists, radiologists, pathologists, neonatologists, assistance surgeons or laboratories.
For Providers and Insurers – ‘Devil in the Details’
With patients being held harmless, the struggle is really between how much non-network providers will be paid by insurers. Hospitals and physicians have opposed any kind of benchmark or standard to determine the amount of the bill, while payers argued for benchmarks. The legislation found a middle ground, giving insurers and providers 30 days to negotiate payment of out-of-network bills. Should this fail, an independent dispute resolution process with an arbitrator would make the ultimate decision.
Needless to say, there are other provisions within this legislation that flesh out many other details on how to settle payment disputes between providers and payers. Thankfully, this backroom process of payment details will not require undue anxieties from innocent patients.
The No Surprise Act will fundamentally fix a problem that existed for a long time. Surprises should only come in packages we receive on special occasions, such as birthdays, anniversaries, or holidays. An unwanted invoice in the mail sent by a non-network provider will hopefully be a thing of the past.
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