Medical Billing Expert

A welcome development in recent times, especially after President Biden came to power is finalizing the details of a ban on surprise medical bills. It is seen by all as an important bipartisan step in consumer protection made by Washington in more than a decade.

Surprise medical bill, the bane of American healthcare system has impacted millions of Americans since decades. It happens when an out-of-network provider or physician gets to treat a patient due to unavoidable emergency and then sends a bill that is way to high by any standards. This is a common practice across the healthcare spectrum because as many as one in five emergency room visits take place out-of-network. The fact that there was no legislation to safeguard consumer interest in such cases was a loop hole in the system which was well-exploited for profiteering.  For instance a murderous Scot Kohan sent him to an in-network ED, but was treated by an out-of-network doctor Sarah Kliff  who sent him a surprise bill of $7,924.

avoid denials medical billing

The new law calls out for treating emergency care situations as in-patient network even if it happens to be out-of-network. In case of non emergencies, the patient will be protected from surprise out-of-network bills if the consent procedures as required by the law are not followed strictly. The law will also roll out a system for computing a benchmark payment that will give health providers and insurers the option to appeal to a neutral body when they feel that amount is not justified. The arbiters shall work as per a “fair” price which will be considered as a baseline for determining how much the insurance plan typically owes the doctor or hospital.

Also Read: 5 Proven Ways of Streamlining Medical Payment Posting and Maintaining Clear Accounts

Providers are a worried. They are worried that the legislation will disproportionately affect the bottom lines of those that treat a high percentage of out-of-network patients which includes hospitals, physician staffing companies, radiology centers, laboratories, etc. If the details of the proposal include fixes such as bundled billing or an in-network guarantee, then the impact will be worse. Yet another apprehension is that small practices will take most of the beating as they will not be able to negotiate with payers on an equal footing like large providers and will eventually have to merge with large hospitals.

While the finer details of the law is yet to come out one thing that it points to is for correct operational strategies which include a proper understanding of out-of-network care, billing process, and a robust mitigation strategy.  Equally important is the need to have proper communications to deal with this act. Let’s understand them in detail.

Here’s What Hospitals Need to Do

Understand the Law

The most important step that providers need to take is to understand the law inside out. As the finer details of the law emerge in the next few months, providers need to stay educated on the new law, understand the clause and sub clauses and map them with their law. There is a lot of understanding to be done in terms of cost sharing, payment process and balance billing, the definition of emergency and non-emergency situations, dispute resolution etc.

A good understanding will enable providers not to take the law on face value but to understand the many situations that may not measure up because of the complexities of payment structure such as multiple providers or non-participating providers etc.

How Outsourcing Can Make the Going Easy

outsource medical billing services

Given the complexity introduced by the new piece of legislation, carrying out normal business would be possible only after the inclusion of additional staff to obtain payment for out-of-network claims. As a third-party provider’s understanding of impropriety or special circumstance has been honed over the years of exposure to US billing need they will be quick to explain you your rights in terms of clear claim payment guidelines, identify grey areas that can lead to violations and penalties and guide you on the best practices in a post-surprise billing era. 

Review Contracts

Once you understand the law, it’s important to review the contracts with respect to emergency and ancillary providers so that you can identify the areas of exposure that can land you in a soup. This again is a complex task because it involves comprehensive knowledge of payer contract management practices and the composite nature associated with negotiating and managing multiple contracts. As per the new legislation, it’s now imperative for payers to publicly post negotiated rates with in-network providers and allowed amounts paid to out-of-network providers. Therefore, every payer contract agreement needs to viewed in light of these disclosures.

Also Read: Why Medical Billing Outsourcing Will Become the Cornerstone of US Healthcare Industry by 2025

How Outsourcing Can Make the Going Easy

Third party support providers have in-depth understanding of payer guidelines and can provide clients an edge in supporting mission-critical pricing strategies and reimbursement needs. Their team comprises payer strategists and market research analysts whose understanding of the new legislation in comparison to the agreements prior to the legislation can help providers dive deeper into contract language, create a central space for contracts, and ready providers for negotiations.

Re-Invent Process Workflows

The impact of prohibiting balance billing for emergency services that operate out-of-network and non-emergency care at in-network facilities delivered by out-of-network providers and pre-determined payment rates for surprise medical bills will push physicians, particularly those associated with smaller practices, into a difficult position. While this will rob them of the chance to compete on an equal footing with large providers, it comes at a time when the 2021 Medicare physician reimbursement schedule is expected to bring about huge reductions in the in-network premiums.

At a time when the odds are stacked heavily them, small practices need to be prepared to reorient their revenue cycle and workflow processes so that they can abide by the legal requirements such as necessary notices, consent form, good faith estimate, balance billing as ushered by the new legislation.

How Outsourcing can Make the Going Easy

Third-party providers are constantly on top of regulatory changes and calibrate the RCM accordingly to meet changing needs. Most RCM service providers are equipped with modern day RCM solutions, that are built to exchange information with other systems, automate workflows to streamline processes and access and provide real-time data. This can help your revenue process to adopt to changing reimbursement model with ease.

Arbitration Team

Whenever there is a dispute with a payer, the arbitration procedure established by IDR allows an independent review of the disputes. As per the new legislation various timelines must be followed during the settlement process, but each entity has to submit the final offer within 10 days of selecting the IDR along with additional information to support their respective offers. To practices need to partner with a robust arbitration team.

How Outsourcing can Make the Going Easy

Though an offshore company may not be directly involved with the arbitration process, they are qualified enough to provide quality legal advice on settling disputes. Most reputed third-party service providers have a sound understanding of the rules that govern the arbitration process. Therefore, if you hire an onshore legal team your onshore partner can shore up the support needed to assist your team to take matters to a favorable solution.

Who are We and What Makes us a Reliable Outsourcing Partner

MedBillingExperts have over 10 decade of experience in providing back-office support services to US-based hospitals. We have over the years assisted payers focus on operational strategies which include improving medical billing process, handling out-of-network care disputes, and developing risk mitigation strategies. We can leverage this experience to assist you take on the challenges posed by the surprise billing legislation. 


Clean Claims On First Submission




HIPAA Compliance


Increase in Collections

Get a Quick Quote

Our Healthcare Software Expertise

Software Tools We Use for Medical Billing and Coding Solutions