Given the market failures and consumer expectations at the heart of surprise billing, it is no surprise that there is pressure for the government to intervene.
What exactly are Surprise Medical Bills?
When a patient is admitted to the hospital, their insurance company and the hospital in question is listed as “in-network,” but when the bill is dispatched, the patient discovers that specific doctors or certain services were out of their “network.” This is the dreaded moment when you receive a surprise bill.
If you’re lucky, your insurance company might pay for a portion of the bill, but often less than the healthcare provider’s list price for the bill. You are then forced to foot the entire outstanding amount – commonly known as “surprise billing.”
Why do you get surprise bills in the first place?
Now that you know what a surprise bill is let’s clarify why do you get them. You might have heard about the preventive care plan that almost everyone has. If you walk into a clinic for a routine checkup, which is always considered preventive, but you unknowingly receive medical care that is considered pre-existing treatment.
Let’s say your physician runs routine checks, and during the examination, you feel a bit of pain. Your physician will ask you different questions as what you’ve been doing lately, do you work out or perform other hardcore exercises. All this will be 100% covered, but when your physician orders further tests to identify the root cause of your pain, that is known as a pre-existing treatment, and this usually isn’t covered in your insurance plan.
But this is just one instance where you’ll receive a surprise bill; there are other scenarios as well. Suppose you decide to get medical assistance from an in-network facility, and you’ve done your homework as well. You might have selected the hospital, the physician, and even the surgeon that is in your network. Still, at times the hospital may deem it mandatory to coordinate with a specialist that is “out of network” like radiologists and anesthesiologists so you can get the best medical attention. In this case, you might end up getting a hefty surprise bill.
What business owners and employers can do about surprise bills?
The best way to avoid surprise billing is by making sure that you have a wide range of in-network healthcare providers that are available for your employees. This makes sure that the people who work in your company have easy access to in-network healthcare providers, which hugely reduces the need for out-of-network care specialists.
Educate your employees
You should also take some time out and educate your employees about in-network healthcare providers. If they don’t know the major differences between out-network and in-network healthcare providers, then you’ll spend most of your time dealing with surprise bills. Educated employees who are aware of the plan and of the in-network providers that will most likely make a wise decision when there is an emergency.
As an employer, you can also guide your employees to use providers that offer the best-bundled pricing for services. These pricing arrangements will prohibit surprise billing.
The No Surprise Bill Act
The new law takes effect for health plan years beginning on or after January 1, 2022 and it applies to nearly all private health plans offered by employers (including grandfathered group health plans and the Federal Employees Health Benefits Program), as well as non-group health insurance policies offered through and outside of the marketplace. The new law contains other related provisions, including a requirement for health plans to keep network provider directories up to date.
If you’re looking for a company that offers a complete suite of billing, coding, and staffing solutions, then you’ve come to the right place. Pettigrew offers Billing and Revenue Cycle Management solutions that are ideal for a wide variety of healthcare organizations.