Tag: surprise billing

HHS Announces Rule To Protect Consumers From Surprise Medical Bills

HHS Reaches First Settlement with Local Government Over ...

The U.S. Departments of Health and Human Services (HHS), Labor, and Treasury, and the Office of Personnel Management, issued “Requirements Related to Surprise Billing; Part I,” an interim final rule that will restrict excessive out of pocket costs to consumers from surprise billing and balance billing. Surprise billing happens when people unknowingly get care from providers that are outside of their health plan’s network and can happen for both emergency and non-emergency care. Balance billing, when a provider charges a patient the remainder of what their insurance does not pay, is currently prohibited in both Medicare and Medicaid. This rule will extend similar protections to Americans insured through employer-sponsored and commercial health plans.

“No patient should forgo care for fear of surprise billing,” said HHS Secretary Becerra. “Health insurance should offer patients peace of mind that they won’t be saddled with unexpected costs.”

Among other provisions, today’s interim final rule:

  • 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.

These provisions will provide patients with financial peace of mind while seeking emergency care as well as safeguard them from unknowingly accepting out-of-network care and subsequently incurring surprise billing expenses.

Tackling surprise billing is critically important, as it often has devastating financial consequences for individuals and their families. Two-thirds exit disclaimer icon of all bankruptcies filed in the United States are tied to medical expenses. Researchers estimate that 1 of every 6 emergency room visits and inpatient hospital stays involve care from at least one out-of-network provider, resulting in surprise medical bills. And a 2019 study by the Government Accountability Office (GAO) – PDF, found that the median price charged by air ambulance providers ranged from $36,400 to more than $40,000, and over 70% of these transports were furnished out-of-network, meaning most or all costs fell to the insured individual alone. HHS, Labor, Treasury, and OPM are promulgating rules that will protect consumers from financial ruin simply because they could not ask for an in-network provider during their treatment.

“No one should ever be threatened with financial ruin simply for seeking needed medical care,” said U.S. Secretary of Labor Marty Walsh. “Today’s Interim Final Rule is a major step in implementing the bipartisan No Surprises Act that will protect Americans from exorbitant health costs for unknowingly receiving care from out-of-network providers.”

“Facing a difficult medical situation is challenging enough – no one should then face a surprise medical bill when they get home,” said OPM Director Kiran Ahuja. “This interim rule helps to protect Americans from financial ruin and honors federal employees, retirees, their covered family members and other enrollees who receive healthcare through the FEHB Program, the largest employer-sponsored plan, by giving them new protections from unexpected medical bills.”

Today’s interim final rule with request for comments implements the first of several requirements passed with bipartisan support in title I (the “No Surprises Act”) of division BB of the Consolidated Appropriations Act, 2021. The regulations issued today will take effect for health care providers and facilities Jan. 1, 2022. For group health plans, health insurance issuers, and Federal Employees Health Benefits Program carriers, the provisions will take effect for plan, policy, or contract years beginning on or after Jan. 1, 2022.

Fact sheets on this interim final rule can be found here and here.

The interim final rule with comment period can be accessed here – PDF.

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The Problem With Surprise Medical Billing

By Terry Rowinski, president & CEO, Health Payment Systems, Inc.

Terry RowinskiWe’ve seen it time and time again—a patient receives services from an out-of-network provider at an in-network facility and is surprised with a huge medical bill months later. Since out-of-network claims can take much longer to process, the consumer often has forgotten the details of the service received and thinks all bills have been resolved, so the bill itself (not just its size) is unexpected.

According to JAMA Network, in the past two years, one in 5 insured adults had an unexpected medical cost due to seeing an out-of-network provider, and two-thirds of adults worried about affording unexpected medical bills for themselves and their families.

Another study, facilitated by the research institute NORC of UChicago, reported that out of 1,000 Americans surveyed, 57% received a surprise medical bill, most often resulting from physician services (53%), laboratory tests (51%), healthcare facility charges (43%), imaging (35%) and prescription drugs (29%). These surprise medical bills are the result of the lack of transparency throughout the healthcare system and leave consumers in the dark.

This blog details this important issue within the healthcare industry and country, as well as how we at HPS are addressing it.

Where the problem comes from

As an industry, we need to accept the reality that the surprise medical bill issue is further complicated by the fact that the entity an individual receives medical care from doesn’t supply all of the consumer bills. A single hospital or office visit could result in up to 10 separate bills, and patients largely have no visibility into the total cost until they receive these bills.

Why, though, are there so many bills for a single visit? Hospitals have multiple departments, physician groups and other entities, and often, each completes and files their own insurance claims and billing processes outside of the hospital. The issue is actually more complex than this, though—it isn’t just the hospital system that might be sending bills. Bills can be generated from multiple locations or entities, making the healthcare billing process more of an ecosystem.

Another reason that this problem is so huge is that there is not, currently, a widely-available solution to the problem, regardless of the use of transparency tools. Someone must actively take up the cause of communicating with the consumer truthfully and in a timely manner, which doesn’t often happen due to how many processes must take place before a consumer can be informed of final costs for healthcare visits, labs, nursing and more.

To help combat the frustration and stress that individuals and their families experience related to confusing and unaffordable medical bills, Health Payment Systems (HPS) has developed its proprietary SuperEOB® (explanation of benefits statement) solution along with various consumer advocacy services via their all-in-one platform.

HPS is a broad provider network offering the most effective independent provider network delivering significant savings and choices for self-funded and level-funded employees, including billing and collections. Their SuperEOB is an easy-to-read statement that consolidates all of an individual’s or a family’s in-network explanations of benefits (EOBs) and medical bills for an entire month in their digital platform, regardless of how many doctors were seen.

In attempting to find a solution to this problem, we must consider how traditional employer insurance holders get billed, how the payer or insurer level handles claims, and how individuals not utilizing traditional insurance plans can be helped.

How to resolve this issue

One possible solution is to create a billing mechanism that the consumer is familiar with, almost like a credit card bill. In this solution, bills would be consolidated into one statement, and consumers could easily understand how, for what, and to whom they owe money.

The solution needed would offer healthcare providers (who are independent of one another) the option of a singular, aggregated billing experience for healthcare consumers. It would give consumers the ability to see which entities have provided services, how those claims have been processed through insurance, and the total amount owed for all services—all in a single billing statement.

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