New No Surprise Act Tackles Unexpected Medical Bills
Two-thirds of bankruptcies filed in the United States are a result of medical expenses. It’s an alarming statistic, but probably not surprising. It’s no secret that many people have trouble paying out-of-pocket medical costs, so much so that a recent survey from The Commonwealth Fund found that 72 million Americans have some sort of trouble with medical debt.
It’s a common problem, but why?Let’s say a person visits a hospital, perhaps an emergency room, and receives a myriad of services. Maybe they arrived via ambulance or required treatment from an anesthesiologist. Although they may inquire about an estimate at the time of service or have an idea of their coverage, the exact financial responsibility is often a mystery. But what’s a person to do? They need medical assistance, and they need it at that moment. Then a surprise arrives in the mail in the form of an outrageously high medical bill. It’s something many of us have likely experienced.
What’s the cause of such an expense? Often the charge stems from using an out-of-network provider. Basically, this means that the hospital may have been in-network, but the physicians were not. Additionally, patients are often confused about medical coverage. Even with a good understanding of their benefits, situations may arise that are out of their control, and there may be unintended outcomes. Patients may (falsely) believe that all services rendered will be considered in-network when they go to an in-network facility. However, this isn’t always the case. In some instances, even though their physician is in-network, patients referred to specialists (such as a pathologist or radiologist) may discover the ancillary services were out of network. It is only after the patient receives a bill that they discover the issue. In the case of an emergency visit, patients don’t have the luxury of researching for in-network hospitals and typically go to the nearest hospitals. Patients may also be taken to out-of-network hospitals by ambulance. Researchers estimate that 1 in 6 emergency room visits and inpatient stays involve care from at least one out-of-network provider. The cost of out-of-network visits can have devastating financial consequences for the patient.
A 2019 study by the Government Accountability Office (GAO) found that the cost for air ambulance services clocked in at approximately $40,000. A large portion of this cost (over 70 percent) often fell out-of-network, meaning that the balance usually was placed on the consumer. When such a service is needed, it’s understandable to not have the option to “shop around” for a cheaper, in-network alternative.
Thankfully, help is on the way. Leaders and policymakers at the federal level have taken steps to tackle the issue. On July 1, 2021, the Biden Administration announced a new rule aimed at protecting consumers from surprise medical bills. In conjunction with the Department of Health and Human Services (HHS), together with the Departments of Labor and Treasury and the Office of Personnel Management, debuted “Requirements Related to Surprise Billing; Part I.”
This announcement, the first in a series, will go into effect on January 1, 2022, and protect patients from those all-too-common surprise medical bills. It’s an important step forward in protecting patients.
“No patient should forgo care for fear of surprise billing,” stated HHS Secretary Xavier Becerra. “With this rule, Americans will get the assurance of no surprises.”
Let’s dive into the new regulation. Among other provisions, the rule:
Protects patients from surprise billing in emergency services. These provisions will safeguard patients in emergency care situations from unknowingly accepting out-of-network care and incurring unexpected expenses.
Limits out-of-network cost-sharing. Patient cost-sharing for emergency and non-emergency services, such as a deductible, cannot be higher than if provided by an in-network provider. Simply put, co-insurance or deductibles must be based on in-network rates.
Bans out-of-network charges for ancillary care. Previously, out-of-network providers like anesthesiologists could have been assigned, even though the facility or physician was in-network.
Requires that providers and facilities provide patients with accurate cost information and advance notice of any out-of-network charges for non-emergency services. A consumer notice must explain that patient consent is required to receive care on an out-of-network basis before that provider can bill at the higher out-of-network rate.
Allows providers and insurers access to a dispute resolution process should reimbursement issues arise around reimbursement.
With the increase in high deductible health plans and increased out-of-pocket costs, finances are top of mind. From the consumer’s standpoint, gaining healthcare services will be less stressful. On the simplest level, this ruling will hopefully eliminate those hefty surprise bills, which can only be seen as a positive. Moving forward, patients can rest assured that they will be more aware of expenses and will avoid out-of-network charges for emergency care.
So can consumers finally say goodbye to surprise medical bills? Hopefully, they become a thing of the past. And how will this bill affect the future of the industry? Advocates are hoping these regulations and newfound transparency will eventually lower costs, for one. More importantly, it shines a light on the need to improve the overall patient experience. It’s a step in the right direction and has the potential to improve healthcare policies going forward for years to come.
For more information on solutions that equip you to have informed conversations about financial responsibility and eligibility, contact a TriZetto Provider Solutions representative today.
ABOUT EZCLAIM: As a medical billing expert, EZClaim can help the medical practice improve its revenues since it is a medical billing and scheduling software company. EZClaim provides a best-in-class product, with correspondingly exceptional service and support. Combined, EZClaim helps improve medical billing revenues. To learn more, visit EZClaim’s website, email them, or call them today at 877.650.0904.
With the cost of insurance premiums and deductibles both on the rise, patients have begun taking on greater responsibility for paying for healthcare than ever before. In return, they are becoming more discerning shoppers and expect more from the patient experience that their providers are delivering. One of the biggest steps that have been taken to create a more standardized, consumer-like experience is the introduction of the final price transparency rule from the Centers for Medicare and Medicaid Services.
More than half of consumers have received an unexpected medical bill
Despite the $3.81 trillion that was spent on healthcare in 2019, America’s healthcare paymentssystem has long remained opaque and broken. Patients are frequently faced with unexpected or surprisingly high medical bills, discover too late that a provider they’d been told was in-network was actually out of network, and are forced to wait 60-90 days to receive their medical bills.
Patients are more concerned about billing than the quality of care
In October 2020, Waystar surveyed 1,000 consumers about their experiences with medical bills, and awareness and attitudes towards the upcoming price transparency rule. More than half of respondents have received an unexpected medical bill, meaning that they assumed a service was covered by insurance and it ultimately was not, or the amount they expected to pay out of pocket was different from the bill they received.
EZClaim is a medical billing and scheduling software company that provides a best-in-class product, with correspondingly exceptional service and support. Combined, they help improve medical billing revenues. To learn more, visitEZClaim’s website,e-mail them, or call them today at 877.650.0904.
Are you working in the medical billing industry as a biller or an owner of a billing company? If so, the KEY medical billing insights and best practices that came out of our interview with Maura Jansen (VP of Operations) and Jennifer Withington (Director of Revenue) at Missing Piece Billing & Consulting Solutions will be VERY VALUABLE for you to consider.
Jennifer, an expert in understanding the problem-solving techniques and the investigative nature of medical billing, offers insights that both educate and inspire. Maura, an executive member of the billing community, also added an important perspective about EZClaim’s medical billing software. The following are some highlights from our interview.
EZCLAIM: When did you get into the industry?
JENNIFER: “I worked in group homes for the waiver side of group aid and then I went to Missing Piece. Missing Piece primarily deals with ABA providers and provides early intervention rendered to children. For me, the move from waivers with adults to professional billing, indirectly assisting children, was attractive and I took to the billing side of things.”
EZCLAIM: What does that mean when you say you took to the billing side of things?
JENNIFER: “Insurance doesn’t make a lot of sense when you first start. So, I took to the investigative side of making sense of medical billing claims. Figuring out what the payer’s rules are, reading their manuals, and figuring out the technical jargon with the purpose of preventing claim denials was attractive. I liked the puzzle of it.”
EZCLAIM: Are there things that you value in your work that offer meaning to what you do?
JENNIFER: “It’s really when I know that if I do not intercede with the insurance company and get this paid the patient is going to be responsible for the balance. So, to help, I have taken things to the department of insurance, or I have gone ahead and filed that third letter of appeal and really taken the time to research it. Because I don’t want a parent who is already struggling with having a child with more needs than maybe the other children would have, I don’t want them struggling with a $25,000 bill. ABA is extremely expensive because it works. And so, if insurance doesn’t pay it then the only other funder is the parent. And my goal is that parents should not have to pay any more than they absolutely have to.”
EZCLAIM: What are some of the strengths that make you good at what you do?
JENNIFER: “I am a good problem solver. I am good at taking a large problem and breaking it into smaller problems and knocking each one down until I solve the bigger issue. At the end of the day, that’s really what accounts receivable is.”
EZCLAIM: What would be an example of your problem solving on a day-to-day basis?
JENNIFER: “So you always start with the denial and then you have to work back to the billing. For example, if I have a claim denied for services rendered from an out-of-network service provider, but we know we are in-network then my first problem is, are we actually in-network? Then, you go onto the next link which is did the payer recognize you as in-network? It becomes like a decision tree, if you get a ‘yes’ then you are probably done, and you get the claim processed. If it is ‘no’, then you have to start digging with the payers contacting reps, make calls, and supply them with documents to get down to why they don’t have your provider listed within the network. Once you solve that problem, then the claim should be able to be processed. It is either going to pay or deny. Then depending on which one it is, you apply the same technique.”
EZCLAIM: What would you offer someone who is considering entering the field?
JENNIFER: “You should be good at processing and reading information because to get a claim paid you to have to know the rules of engagement. You need to be familiar with how to read a contract, how to read technical information about billing, and have to have a glossary of information about what you are billing. Those are the building blocks to get to know what you are doing.”
EZCLAIM: You work with EZClaim’s medical billing software platform, what role does their software providers and how does that impact your work?
JENNIFER: “EZClaim really serves to eliminate these denials before they happen, which is the ultimate goal of any accounts receivable or billing. EZClaim has edits that we use. It alerts us if the system thinks the claim is a duplicate, for example. It also helps in the set-up of the claim. We load all the fee schedules in EZClaim’s procedure code library and that lets us monitor the charge rate, make sure all the points of billing are on the claim (i.e. correct code, modifier, and charge). They also make sure that the authorization is appended to the claim. And then after we have actually done the work of getting a claim in the system, we use EZClaim reports to audit our own billing. So, we use the EZClaim service report. It makes it easier for us and our providers to see what has been billed and make sure that the billing is correct.”
EZCLAIM: If you were going to share something with your colleagues in the field, what would you share about the software that makes your life easier?
JENNIFER: “Number one, it is not the software itself, it’s the EZClaim staff. Their customer service is far beyond what a normal billing software company provides. If I have a problem, or if I have a report, or if I have a data point that isn’t in any report, they are available and they are there for me. And if they don’t have a solution for the problem, they will provide me with a workaround. So, that is very valuable. That is why Missing Piece works so well with EZClaim because customer service is number one for us, too. They don’t just want to answer your question, they want to help you understand your question.”
“The other thing that I find valuable is that their reporting modules are just a lot more robust than the other billing software companies that I have dealt with.”
EZCLAIM: Maura, do you have any thoughts from an administrative level that you can offer on EZClaim?
MAURA: “Well, when we hire a new person we know that, even if this person has very little experience in the healthcare field, it’s going to be a quick and easy process for them to learn EZClaim… EZClaim has also made it kind of a joy to work with. We really value them as a partner. We love the service they provide, and we value them as a platform.”
ABOUT EZCLAIM: EZClaim can also help you with medical billing insights since it is a medical billing and scheduling software company. It provides a best-in-class product, with correspondingly exceptional service and support. Combined, they help improve medical billing revenues. To learn more, visit EZClaim’s website, email them, or call them today at 877.650.0904.
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