PATIENTS AND PROVIDERS IMPLICATIONS

On January 1, bipartisan legislation went into effect that bans surprise billing for out-of-network costs for emergency care. This legislation was signed into law in December 2020 as part of a bill funding the government through 2021, and it required the Department of Health and Human Services to protect patients from “outrageous” bills beginning January 01 of 2022.

According to a section-by-section breakdown, the No Surprise Medical Bills Act would have the following implications for patients and consumers:

1. Patients are only required to pay the in-network cost required by their health plan for emergency services, regardless of being treated out-of-network.
2. Patients will not foot surprise costs for additional health care services after receiving emergency out-of-network care.
3. Patients will owe no more than their in-network costs if a non-emergency service is provided by an out-of-network provider at an in-network facility.

The No Surprise Medical Bills Act would have the following implications for Hospital and other healthcare providers:

1. Review and improve billing processes: Providers and payers should review their data systems to make sure they can deliver accurate cost estimates for patients. They also should review the systems used for insurance verification as the accuracy of those processes will be essential once the changes to surprise medical billing take effect. 
2. Review out-of-network care: Payers should review all the situations when out-of-network care might occur, assess the potential financial impact, and expand out-of-network mitigation strategies to prevent “balance billing” situations. Payers and providers should understand when to pursue arbitration, as each side will try to use leverage to force rates up or down, or control networks. 
3. Implement notice and consent communications systems: the regulation offers an exception to allow for balance billing in cases where a patient in a nonemergency situation can choose an out-of-network provider with the understanding that payers will not cover the full bill and they will be responsible for extra charges above their cost-sharing. Providers should implement new processes and documentation systems to make sure they have proof of the notice and consent; and consider clear communication strategies and identify the patients who fall into the category that might be interested in paying for certain providers.