Studies have shown that medical debt is the leading cause of personal bankruptcies. People who are aware of this statistic often put off necessary medical procedures to keep themselves financially afloat. The No Surprises Act has been enacted to help those who are fearful of possible medical bills. The act will require that patients are only required to pay in-network cost-sharing amounts for out-of-network emergency care, attributing the cost to the patient’s in-network deductible. Medical plans are required to make payments to providers, but there is no federally-set benchmark, which makes things a little tricky. Due to that fact the law provides for a 30-day negotiation period, this way providers and insurers try to settle out-of-network claims. If they do not come to a resolution within that timeframe, they will need to access a binding arbitration, known as an Independent Dispute Resolution, or IDR.
An IDR is administered by an independent, unbiased, and unaffiliated third party. This person, or entity, is required to consider median in-network rates, alongside the relevant information presented by both parties and information requested by the said reviewer. This arbitrator will also need to take into account the training and experience of the provider, as well as the complexity and service that was furnished to the patient in its assessment of payment from the insurer. Once the determination from the IDR is made the IDR may not take the same party or similar claim for a 90-day period, any claims made in that time period will still be eligible for IDR upon completion of the 90 days. Balance bills are only permitted when the provider gives the patient sufficient notice of their network status. Sufficient notice is quoted at 72 hours prior to receiving services or care. In the case of appointments made within that timeframe, the patient must receive notice the day the appointment is made and deliver consent to the out-of-network care.
Air ambulance bills demonstrate another sector of surprise billing. Since air ambulances are used, generally, when a patient needs the most immediate help and requires being transported from an accident or incident in the most rapid way available. This sort of transportation is used when a patient cannot be taken by car or roadway, due to external factors, and the ability to accurately and most quickly move the patient would be by air. Patients would be required to pay only the in-network cost-sharing amount for out-of-network air ambulances. There is a provision for a 30-day open negotiation period for air ambulance providers and insurers to settle these out-of-network claims. In the case that there is no resolution in the 30-day period they would move into IDR, which would be a baseball-style binding arbitration. In this evaluation, the IDR entity is required to consider the market-based median in-network rate, as well as information brought by both parties related to the training, experience, and quality of the provider, as well as the population density of the location and air ambulance vehicle type along with the complexity of furnishing the item or service to the patient.
Gables Medical Billing has adapted to the ever-changing medical billing environment, modifying and adding to its services to proactively meet the needs of its clients.