The Impact of the Surprise Billing Act on Medical Billing Services in 2023 and Ways to Deal with It

One shocking element of medical billing services is surprise billing. It happens when a patient receives unexpected charges from a healthcare provider outside their insurance network. This can happen in several ways, such as when a patient receives care at an out-of-network hospital or clinic or when an out-of-network physician or specialist at an in-network facility treats them.  A recent study found that surprise bills affect millions of US citizens yearly. This is because every one in five emergency room visits is an out-of-network visit. Out-of-network anesthesiologists, emergency room physicians, and ambulances primarily generate surprise bills to shock patients. 

Did You Know  

The average in-network emergency room visit is around $600-$ 1000. However, for the same emergency room visit in out-of-network hospitals, the charge can be up to $100,000

How has Surprise Billing Cheated Patients 

Surprise billing occurs when patients receive unexpected charges from out-of-network healthcare providers, often after receiving emergency care or undergoing a procedure at an in-network facility. For example, this can happen when an out-of-network doctor, such as an anesthesiologist or radiologist, is involved in a patient’s care without their knowledge. Patients can also be billed for services they did not receive or were not pre-authorized. These unexpected charges can lead to financial burdens and stress for patients, who may be unable to pay the bills or may be forced to pay more than they can afford.  A patient is likely to receive a surprise bill under the following circumstances: 

1. If a patient has been the victim of surprise billing, it may have happened in several ways. Some examples include:
2. The patient received care at an out-of-network facility: If they received care at a hospital or clinic that is not in their insurance network, they might have been charged more than they expected.
3. An out-of-network physician treated the patient: If the patient received care from a physician or specialist not in their insurance network, they might have been charged more than expected.
4. The patient received care for an emergency: If the patient received care for an emergency, they may have been taken to an out-of-network facility or treated by an out-of-network physician, even if he would have preferred to receive care at an in-network facility.
5. The patient received care for a pre-approved procedure: If the patient received care for a pre-approved procedure, they might have unknowingly received care from an out-of-network provider.

How are Patients Getting Affected by Surprise Billing

Surprise billing can affect patients in a variety of ways. Some examples include: 

1. Financial burden: Patients may receive unexpected medical bills they cannot afford, leading to financial stress and difficulty paying for other necessary expenses.
2. Difficulty obtaining care: Patients may avoid seeking necessary medical treatment due to fear of receiving surprise bills, which can ultimately lead to worse health outcomes.
3. Lack of transparency: Patients may need help understanding the costs of their medical treatment and may need to be aware of surprise bills, leading to confusion and frustration.
4. Limited provider choice: Patients may be limited in their choice of providers if they are not in-network for a particular plan, which can restrict access to care.
5. Conflict with insurance: Patients may be forced to navigate disputes with their insurance provider over unexpected charges, which can be time-consuming and stressful.

What is the Surprise Billing Act  

The Surprise Billing Act is legislation aimed at protecting patients from surprise medical bills. The bill has changed the way patients are charged beyond reason. The bill now mandates health providers to talk to insurers to settle on a fair price. The new changes apply to small and medium-sized practices, individual doctors, hospitals, and air ambulances (ground ambulances are exempted). Some of the main features of the act include: 

1. Protection against unexpected bills: The act aims to protect patients from receiving unforeseen bills for out-of-network services.
2. Cost-sharing limits: The act limits the amount patients must pay for out-of-network services.
3. Provider reimbursement: The act establishes a process for determining reimbursement rates for out-of-network providers.
4. Transparency: The act requires providers to inform patients if they need to be in-network and to provide cost estimates for services in advance.
5. Dispute resolution: The act establishes a process for resolving disputes between providers and insurance companies over reimbursement rates.
6. Prohibition of balance billing: The act prohibits providers from billing patients for the difference between the amount that the provider charges and the amount that the insurance company pays.

Did You Know  

In the last few years, the problem has compounded. This is because some practices have turned surprise billing into a profitable business model. The model involves pushing providers out of the network so that charges can be bloated and buying out-of-network emergency doctors. 

1. Healthcare providers cannot send a balance bill to patients for availing emergency services out-of-network.
2. Healthcare providers can only charge balance bills from patients for out-of-network non-emergency services if they meet consent requirements for certain services.
3. All practices and hospitals are mandated to reveal all the measures it has in place to prevent balance billing
4. Out-of-network air ambulance providers cannot balance bill patients for covered air ambulance services
5. In the case of out-of-network have to charge patients, the cost-sharing for insured patients has to be in keeping with the amounts charged by in-network levels
6. providers must furnish a reasonable faith estimate that explains likely charges to self-pay patients before three working days of the appointment date.
7. Insurers and healthcare providers need to ensure continuity of treatment even if there is a change in the provider’s network status
8. Insurers and healthcare providers must take all necessary measures to maintain provider directory information up-to-date
9. AN out-of-network physician is permitted to bill a patient at an out-of-network rate for treatment availed at an in-network facility only after providing disclosure to the patient and obtaining the patient’s written consent at least three days before the appointment.

Why is the Surprise Billing Act Difficult to manage? 

Surprise billing can be challenging to manage for several reasons: 

1. Lack of transparency: Patients may only sometimes know which providers are out-of-network and may receive unexpected bills for services they thought were covered by their insurance.
2. Complex billing systems: Medical billing can be complex, with many different codes and procedures that can lead to confusion and errors.
3. Difficulty in determining fair reimbursement rates: There often needs to be more agreement between providers and insurance companies on what constitutes a reasonable reimbursement rate for out-of-network services, which can lead to disputes and unexpected patient bills.
4. Limited patient understanding: Patients may need to fully understand their insurance coverage or the billing process, which can lead to confusion and unexpected bills.
5. Insufficient regulations: Surprise billing is a complex issue that is only sometimes addressed by existing rules and laws, making it difficult for providers and patients to navigate the system.

Surprise billing is a complex issue that takes work to solve and involves multi-stakeholder and multi-level solutions. 

The Updated Surprise Billing Act in 2023 

In 2023, the final rules of the No Surprises Act were released. The final rules detail the QPA (qualified payment amount), the insurer’s average in-network rate for a service, and the IDR (federal independent dispute resolution) process. From this year onwards, providers need to give additional documentation for the QPA to eliminate the plausible factor in charges made. The QPA will be first read by certified IDR entities, who will also look into other additional information to determine the correct out-of-network rate. 

How can Providers Prepare Themselves for the Surprise Billing Act in 2023 

Providers can prepare themselves for the Surprise Billing Act in 2023 by familiarizing themselves with the provisions of the Act and assessing how it will impact their billing practices. They should also review their contracts with insurance companies and work to negotiate more favorable terms that will protect them from financial losses under the new law. Additionally, providers should consider implementing systems and processes that will help them identify and prevent surprise billing situations. This includes working with their billing and coding staff to ensure they correctly code and document procedures and stay up-to-date on the latest regulations and laws related to surprise billing.  Medical Billing Services 2023: The Do’s and Don’ts of the New Surprise Billing Act  In 2023, practices need to be cognizant of the following aspects of medical billing services: 

Good Faith Estimates 

The No Surprises Act of 2023 also aims to protect uninsured citizens. It mandates the providers to give a reasonable faith estimate of the likely charges before the treatment. To benefit the uninsured, providers must put up a reasonable faith estimate of expected treatment charges on-site. Likewise, the good faith estimate has to be published prominently on the provider’s website. 

Outsource Medical Billing Services to Stay Compliant with the No Surprises Act 

An accurate understanding of the requirements of the No Surprises Act & Good Faith Estimates will help you stay away from committing balance billing mistakes both in case of non-emergency and emergency billing. Medical outsourcing companies can help you implement the No Surprises act accurately.  OutsourceRCM, one of the most well-known medical billing companies, has over a decade of experience in medical billing services and will leverage this experience and knowledge to enable you to bill accurately under the No Surprises Act and provide the correct estimates under the good faith estimate act to your patients. To learn more about our medical billing services, contact our experts now.