• Angel Callaway, CPC, CPB

No Suprise Act

Many patients are faced with surprise medical bills after a procedure or hospitalization despite the best effort of the provider and patient to assure this does not happen.


In a surgery by Healthcare Financial Management Association's Pulse Survey Program, financial leaders at hospitals said the incapacity to estimate reimbursement for out-of-network providers who participate in procedures, such as anesthesiology. An in-network hospital may still have out-of-network providers and patients in an emergency situation may have little or no choice when it comes to who provides their care.


According to a Kaiser Family Foundation study, one in three insured adults experienced a surprise medical bill and one in six insurance adults experienced an out-of-network bill. With the average surprise medical bill over $500, this places the patient in financial hardship.


Stopping surprise and out-of-network bills all starts with transparency from the time of scheduling to follow-up appointments after the procedure. Going over and explaining the patient's insurance benefits and related costs can go a long way with preventing the cost and help the patient be more prepared for the associated expenses.


The new No Surprise Act effective on January 1st, 2022 requires providers and payers to dispute out-of-network rates when surprise billing occurs. Providers are required to give good faith estimates of expected charges for scheduled health services and may have to participate in a patient-provider payment dispute resolution process if their billed charges are higher than the good faith estimate. The Surprise act restricts surprise billing for patients in job-based and individual health plans who get emergency care, non-emergency care from out-of-network facilities, and air ambulance services from out-of-network providers.


Time frames for the dispute have been established and must be followed. Uninsured patients may initiate the process within 120 days of receiving the initial bill for services that are substantially higher than the expected charges of the good faith estimate. The earlier the dispute process is started will result in better client relations and resolution of the dispute.


Department of Health and Human Services has issued a guide for Patient-Provider Dispute Resolution Process (PPDR), you can access it here https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/Guidance-Selected-Dispute-Resolution-Entities-Required-Steps-Making-Payment-Determination-Under-Patient-Provider-Dispute-Resolution-Process.pdf




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