When seeking medical attention, the last thought in your mind should be whether you will wind up with extra bills out of the blue. Unfortunately, when it comes to surprise medical billing, many Americans are all too familiar with this scenario. According to the Centers for Medicare and Medicaid Services (CMS), one of every six emergency room visits, and inpatient hospital stays involve care from at least one out-of-network provider, resulting in surprise medical bills. Surprise billing occurs when you see an out-of-network provider, and the provider charges you the remainder of what your insurance did not pay.
Now, when you have an emergency, you will usually be taken to the nearest hospital. But even if the hospital is in network, there is still a possibility that you may receive care from out of network providers like an anesthesiologist or radiologist. When you are not able to choose in-network providers, your overall health care costs can add up quickly. In addition to out-of-network copays, you may receive a balanced bill from the provider or facility, aka a surprise bill.
Since medical expenses are the main contributor to two-thirds of all bankruptcies in the United States, this problem needs dire attention. Hence, AMAC’s support of last Congress’ H.R. 3502, the “Protecting People from Surprise Medical Bills Act.” We have listened to our members’ concern over this billing issue, and we wanted to ensure they were heard. And an end could be in sight!
On July 1st, 2021, an interim final rule was issued through the U.S. Departments of Health and Human Services (HHS), Labor, and Treasury, and the Office of Personnel Management to limit exorbitant out of pocket costs to consumers from surprise billing.
Among other provisions, the interim final rule also:
- Bans surprise billing for emergency services. Emergency services, regardless of where they are provided, must be treated on an in-network basis without requirements for prior authorization.
- Bans high out-of-network cost-sharing for emergency and non-emergency services. Patient cost-sharing, such as co-insurance or a deductible, cannot be higher than if such services were provided by an in-network doctor, and any coinsurance or deductible must be based on in-network provider rates.
- Bans out-of-network charges for ancillary care (like an anesthesiologist or assistant surgeon) at an in-network facility in all circumstances.
- Bans other out-of-network charges without advance notice. Health care providers and facilities must provide patients with a plain-language consumer notice explaining 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.
Ending surprise billing is crucial as it can have excruciating financial consequences for those who are affected by it. No one should go into debt for receiving care from out-of-network providers without their knowledge. This new rule will save those who were not able to ask for an in-network provider at the time of treatment or were treated by non-participating providers without their knowledge. These new regulations set for providers, facilities and insurers are set to take place January 1st, 2022.
While these are very positive aspects of this interim rule, a critical component of it has not yet been issued. It concerns the independent dispute resolution process. AMAC’s advocacy affiliate, AMAC Action, has previously recommended a transparent, free-market approach to resolve payment disputes between physicians and hospitals. It includes a third party using historical voluntary payment data made by the insurer three years prior to any rule or law being enacted and/or the use of an independent database, whichever is greater.
It is important that the interim rule reflects an arbitration process that fosters price transparency and is free of any outright or functional benchmarking of prices which amounts to price-fixing and hampers the negotiation process. As of right now, we will be watching for when CMS discloses the independent dispute resolution provision. At that time, we will provide further comment on its structure and functionality.
Call 1-800-334-9330 and one of AMAC’s trusted, licensed Advisors will be happy to assist you with your needs