Unexcepted healthcare cost for medical procedures has become a growing concern for many Americans. The occurrence of surprise medical bills has inspired legislative action from Federal government in the form of the No Surprises Act. However, some healthcare providers strongly disagree with the details of the legislative act.
Conversations surrounding how to control healthcare expenses has been a popular topic for many years. There has been many discussions and attempts to control medical cost. All of this was a major motivation for the creation and passing of the No Surprises Act.
Large facilities and smaller practices are all forced to deal with patient billing issues. When patients receive surprise medical bills, these tend to create negative, toxic feelings toward the healthcare industry. Preventing these bills is a step in the right direction, however the implementation and details in doing this is not without its challenges.
What Is the No Surprises Act?
This federal legislation provides some level of financial protection from surprise bills for certain healthcare procedures. U.S. Department of Health and Human Services (HHS) stated that surprise medical bills are fairly common for individuals with private insurance. For example, these bills can average more than $2,600 for surgical assistants.
The No Surprises Act requires accurate pricing transparency for healthcare treatments and plans. The act prevents medical bills for certain services from out-of-network providers at in-network facilities. However, this is only if the patient did not choose or know that the medical service would be delivered by an out-of-network healthcare provider.
Also, patients are only financially liable for in-network expenses. Many state governments have enacted laws that provide some measure of consumer protection, but this federal act provides additional safeguards.
Specific non-emergency out-of-network ancillary services may not be billed beyond their in-network cost-sharing amount. This applies even if the patient received notice or consented to the service. These services include: anesthesiology, pathology, radiology, neonatology and laboratory services.
Other significant parts of the act include:
- The ability for healthcare practitioners and insurance providers to separately negotiate reimbursement rates.
- Patients are financially liable for only the usual in-network expenses.
- If needed, an independent dispute resolution process for patients.
Challenges to the No Surprises Act:
Many of the provisions of the act sound beneficial, however some medical organizations and healthcare associations are arguing that the legislation is flawed. Most of the arguments are focusing on how out-of-network reimbursement disputes are settled.
The AHA (American Hospital Association), AMA (American Medical Association) and others have all filed lawsuits against the No Surprises Act. They argue that the act is misguided and will negatively impact hospitals and healthcare providers.
The plaintiffs in the lawsuit argue that the new regulations will damage the independent dispute resolution process while unfairly benefiting larger commercial healthcare insurance companies. They feel that this dispute resolution bias will discourage fair insurance contract negotiations.
Critics feel that overall access to healthcare is reduced by shrinking medical provider networks, while simultaneously encouraging unsustainable reimbursement rates for teaching hospitals, physician practices as well as other healthcare clinicians.
The AAMC (Association of American Medical Colleges) argues that the No Surprises Act generates reduced incentives for insurer companies to maintain and expand medical provider insurance networks. They also feel that the new federal act will narrow the size of existing insurance networks, which will eventually lead to fewer in-network choices for patients seeking medical treatments.
The AAMC would like some of the rules changed so that the market size (shares) of both insurance payers and healthcare providers are a deciding factor, as well as the patient acuity.
Critics of act also point out that these new regulations require medical providers to submit the cost of treatments for patients who are either uninsured or choosing to pay out-of-pocket. Even before the No Surprise Act, reimbursement rates for services rendered was a divisive issue for medical providers. Under this new act, critics argue that these listed prices will create confusion due to the fact that patients will likely not understand the listed medical codes, items and procedures.
Additional confusion may occur because many health systems use a fee schedule that is on a sliding scale for patients with a lower income. This means that these individuals will have a different fee schedule.
As of the date of publication, it is still not clear as to how healthcare facilities and providers will be monitored. Industry observers will also monitor whether the No Surprises Act will reduce or stop surprise medical bills for patients. The ACA (Affordable Care Act) does grant the federal government the power to require transparency in data reporting. However, it looks like the courts will have to settle the details of the act.
At Advanced Billing & Consulting Services (ABCS), we provide revenue cycle management services for a number of healthcare specialties. In addition, we offer workforce management tools for I-DD agencies, online advertising services as well as insurance credentialing.
For additional questions about this topic or medical billing in general, please call 614.890.9822 or email us.
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