Surprise billing in healthcare is one of the top issues that the Federal Government and the medical
industry authorities like the CMS have been fighting for long. The rules aim to bring more
transparency in the medical service industry and provide the patients with a better experience
through the quality of service and less complicated billing parameters. Surprise medical billing has
been an area of contention for a long time. While several healthcare organizations suffer from the
backlogs of revenue, patients find themselves with a complex billing charge of great value for any
emergency service they might have taken a few months back.
The No Surprises Act came into effect on January 1, 2022. The law prevents any healthcare system
from billing the patients a considerable amount due to the emergency services from an out-of-network
provider or an out-of-network healthcare facility. While the clauses of the new regulation have been
designed to shed more light on the medical billing workflow, some
issues still need immediate attention
to ensure the proper implementation of the rule. Here are some barriers that might hinder the
prevention of surprise billing in healthcare.
Unpredictable Ancillary Services:
Emergency medical services at any healthcare facility could be challenging to predict when the
patient walks through the door. It is because a healthcare service includes a team of providers like
doctors, nurse practitioners, and many others like anesthesiologists.
According to the American Hospital Association reports, 1 in 6 hospitalizations has an
out-of-network bill from an insured patient. With the NSA in effect, the healthcare facility cannot
bill the patient more than the applicable in-network cost-sharing amount.
To ensure more transparency in the system, the hospitals and other health systems also need to
inform the patients about the estimated costs of the medical services scheduled for them in good
faith.
However, not all healthcare providers at the organizations have a predictable service charge. For
example, ancillary providers like anesthesiologists work under a contracted system. It is difficult
to predict the bill in good faith with several providers not having their charges streamlined into
the system.
There should be an established system on how these costs will be calculated to ensure that patients
get the real benefit of the No Surprises Act during emergency services. Removing this barrier will
help the health systems to provide a better service and an excellent overall experience for the
patients.
Patient Financial Services:
The Centers for Medicare and Medicaid Services and several other American healthcare authorities
have published helpful resources to guide the healthcare organizations to prevent surprise billing
in healthcare.’
Most of these resources have highlighted the need for proper counseling of patients regarding their
financial options when discussing their medical bills during an emergency.
On the one hand, financial counseling helps the patient get a clear view of the options at hand. On
the other hand, it becomes easier for the healthcare organization to realize their rightful revenue
once the final bill reaches the patient.
However, not all healthcare facilities are equipped with a large team to handle this part of the
business. You need competent medical finance professionals in your team to guide the patients with
their options. Once the medical organizations of all scales get a fair view of their financing
options, they can help the patients and pass on the rippling benefits of the Act.
If you are struggling with a short-staffed team at this time, get in touch with an experienced team
of RCM professionals who can guide you with the best practices and train your team to improve the
overall efficiency.
Incomplete Patient Registration Process:
Patient demographic details taken during the registration process should be dealt with caution when
moving forward with the subsequent billing procedure.
With the NSA in effect in current times, it is essential for the healthcare organization to have a
streamlined process where they can gather and verify the information within a short span of time.
The revenue cycle management team handling your regular patient accounts needs to take down the
necessary information from the patient during the onboarding process and check with the
corresponding insurance panel to know the sharing cost for an in-network provider.
Different insurance panels have separate systems of contact. It is advisable that the team working
at the facility is equipped with a system that can quickly respond to the given data points and
fetch the results within a short span of time.
Most healthcare facilities struggle with the registration process where they are unable to gather
complete, correct data from the patients during the first step of the process. Software tools
developed by RCM companies could help them with the verification process much faster, thus enabling
fewer erroneous medical bills in the future.
Coordination with Insurance Companies:
Successful implementation of the No Surprises Act in health systems of different scales requires a
superior level of coordination between the billing team in the healthcare organization and the
insurance companies of the patients.
The NSA requires that each healthcare system reach an agreement with the insurance company the
patient is under regarding the payment of the out-of-network bills. The convention is that the
out-of-network charge will be aligned with the median charge of the in-house providers.
Experts feel that it is in the best interest of both that they arrive at a conclusion on their own
rather than going for the Independent Dispute Resolution (IDR) system, the next part of the NSA.
This clause means that healthcare organizations need to be in touch with the insurance companies at
all times to reach a conclusion. It will ensure a smooth flow of revenue without unnecessary delays.
Teams working under billing in healthcare should now be proficient in handling the constant
communication with the insurance panels to ensure that the best interests of both are met, and the
cash flow is strong.
We hope this article helped you understand the barriers to overcoming surprise billing in
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