A New Law Takes Aim At Surprise Medical Bills

The last thing you want after surviving an accident is to find that you have been charged an exorbitant amount for being taken by helicopter to the nearest hospital, where a doctor performed immediate surgery to save your life.

New legislation passed by Congress seeks to protect patients from unexpected medical expenses. Read on below for more information about the No Surprises Act.

The No Surprises Act was passed in late 2020 as a way to help protect consumers from receiving high medical bills for necessary treatment, just because they have a certain health plan.

The No Surprises Act will apply to all health plan years that start on or after the first of January in 2022. It applies to the vast majority of employer health plans (private healthcare plans) and non-group healthcare policies that are offered within and without the marketplace.

As it stands, providers are currently able to bill a patient for the difference between the rate an out-of-network provider charges and the amount the health plan will reimburse. This is called balance billing and is responsible for millions of dollars billed to patients every year.

Under the No Surprises Act, a health plan cannot hold a patient liable for unexpected expenses from out-of-network providers. These kinds of expenses are usually incurred in emergency situations where patients must receive treatment at the nearest facility, which may not be in their network. In non-emergency situations out of network, costs may be incurred by a specialist like an anesthesiologist from whom the patient did not elect to receive their care.

Several aspects of surprise bills are covered under the new law. Private health plans must now cover services at in-network rates, including emergency services like air ambulance and non-emergency out-of-network services. 

These must be covered with no prior authorization required and a “recognized amount” will be used as the basis for determining what the cost-sharing should be. This will typically be the median amount that is covered by the healthcare network for the same service or near enough to use it for a cost comparison. Medical billing experts are typically knowledgeable about these median amounts in their area and can help inform decisions in this regard.

Balance billing—described above—is now prohibited under private plans, it was already prohibited under the Medicare and Medicaid public plans.

Out-of-network providers cannot pass excess charges along to the patient. There is language in the law that prevents providers from directly billing patients for the full amount of services and issuing refunds only if patients knew they were protected from surprise billing and sought compensation. The new “shall not bill” language puts the responsibility on the providers to determine appropriate billing with regard to the patient’s insurance status.

Due to a disagreement in Congress as this issue was debated, there is a compromise in how payment amounts for surprise bills will be negotiated: An Independent Dispute Resolution (IDR) process is available for any surprise bill after a period of 30 days where the plan and the provider try to come to an agreement. Each party will submit terms and the IDR decides which is the winner. The decision is final and legally binding, and whoever loses must pay for the cost of the arbitration – this is designed to encourage everyone involved to submit reasonable bids.

Patients can plan ahead for their treatment by acquiring an explanation of benefits in advance, showing what the health plan will pay for and what the patient will ultimately pay for their services.

If a provider leaves the network, health plans must provide continuing coverage at the in-network rate for 90 days after the departure, or until treatment is complete, whichever happens first.

As with any resolution, it is not perfect, and the No Surprises Act is open to potential issues with its implementation. These new requirements create significant effort requirements for providers and health plans, and it is uncertain how well IDR entities will handle the capacity of disputes.

In addition, an extraordinary amount of data will have to be collected, collated, and made public. For each bill that resolved by the IDR process, the Secretary of Health and Human Services must post the identity of each party, the location where they are in the country, and the nature of the surprise bill. 

The out-of-network payments pose an incentive problem as well for health plans and providers. If the required payments are too high, then providers may leave the networks. If the payments are too low, health plans may not be competitive in the amounts they pay to keep providers in their network. Medical billing experts will have many new standards to consider as early as the first of July in 2021 when the first steps of this law are implemented.

It is highly recommended to hire medical billing experts to determine and testify to the reasonable value of medical service. The provider’s location can affect these costs and reimbursements.

Whether you are a plaintiff or a defendant in a case, o ne of the most important items in Automobile, Personal Injury, and Medical Malpractice cases is the cost of medical bills. Figuring out medical costs can be complicated, and expert guidance is critical to ensuring you have a clear understanding of what is “fair and reasonable” with regard to the finances involved in your medical care.

Medical Billing Analysts offers litigation support services nationwide, with offices in New York, New Jersey, Connecticut, Pennsylvania, Georgia, Florida, Texas, Nevada & California. Medical Billing Analysts represent both defendants and plaintiffs with regard to improper medical billing and coding.

The team of MBA professionals will review the hospital, medical and therapy bills to determine the value of past medical expenses, and based on local CPT codes they can also perform a Cost Projection Analysis of future costs.   Through meticulous analysis, we can justify the reasonable cost of services that assists in resolving the case.

Contact Medical Billing Analysts by phone or email at 800-292-1919 or intake@medicalbillinganalysts.com . We’re here for you, whether you need an evaluation of a single charge or a complex injury case.