You can start by asking: What exactly is a “surprise” medical bill? Well, put simply, it’s a bill that occurs when a person seeks care at an in-network hospital or healthcare facility but is treated by an out-of-network physician. They’re also called “out-of-network balance bills”, they’re usually unexpected to the patient and they tend to feel they have no control over them.
Okay, but give me an example. You broke your arm, the hospital you go to is in-network, so you naturally assume all the doctors and staff are also in-network. You’re treated, during surgery by an out-of-network anesthesiologist. A few weeks later get the surprise bill for $650, for their time and their Propofol.
This sounds uncommon, are you pulling my leg? Actually, this isn’t that uncommon. One study saw it in 1 in every 5 emergency cases of 2-million.
Something has to be done about this, it’s a travesty! Actually, thanks to the US Government we’re supposed to never see this happen again, except for cases of ground ambulances.
So, what exactly does this mean for me? Well, effective January 1, 2022, the No Surprises Act will be here and in action. This will mean that insurers are generally forbidden from dropping high out-of-network bills on patients, and instead need to sit at the negotiating table with providers and work out a deal between themselves. Our patients will be paying any visit as if, no matter the doctor’s coverage status, they were in-network. This will leave any balance to be settled by the providers and insurers. The law gives 30 days to providers and insurers to sort out the payment. If, within those 30 days, there is no settlement made the case enters arbitration.
This means that both sides, the practitioner and the insurer put forth their offer and an arbitrator will choose one, the loser then pays the arbitration fee. That fee is set between $200 and $500 for 2022. The act also states that either party can object to an arbitrator, with another selected that has no ties to the insurer or physician in question. The rule specifies that the amount closest to the median in-network rate is what arbitrators should generally choose. Other factors, such as the hospital type, the complexity of treatment, and the experience of the provider can be taken into consideration without giving them equal weight.
The government has also barred the consideration of the highest amounts and lowest payment options. Outside sources have said that this new law will push providers to join insurer networks, as you cannot rely on staying out of network and depending on arbitration and the federal process to obtain higher reimbursement rates. When the law is in effect emergency scenarios will be simplified for patients, as for them they will be paying the same regardless of the provider’s status. That seems like a check-in everyone’s column, the patient gets top notch treatment without the fear of a mystery bill, the provider has negotiated their rate with the insurer and will be paid likewise and the insurer has a set payment for each provider or they can head to arbitration.