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What Exactly Is Surprise Billing and How Does It Impact Me?

August 23, 2021 clarification on surprise billing

Health Insurance Payers Ask: How Should I React to the No Surprises Act and the Latest Surprise Billing Rule? That's a great question and we'll attempt to provide some definitive answers.I think we would all agree that there are still some surprises left in the No Surprises Act.

There is good news though. The Act is addressing some long-standing issues that have adversely affected the healthcare market. And with some excellent go-to resources and strategic planning, you can manage the financial risks posed by surprise medical bills.

Can we ask a quick question before we get started? Do you want to pay less for every medical claim? That's the goal we have for our clients at H.H.C., so we apply a combination of technology, experience, and bulldog tenacity to achieve the greatest savings possible. We have targeted solutions for health insurance payers who don't like surprises!

In this blog, we'll discuss:
  • The Impact of the No Surprises Act and the July 1, 2021 interim final rule (IFR)
  • How the Act Affects the Patient and the Payer
  • Strategic Solutions for Payers

We'll frame the discussion in the context of the latest HHS guidance, aka "Requirements Related to Surprise Billing; Part I." Remember, with healthcare billing, forewarned is truly forearmed! So let's dive right in.

Surprise billing has been a controversial issue for a long time.

According to health analytics firm Health System Tracker, over two-thirds of Americans are very concerned about the potential consequences of surprise medical bills. It's also estimated that one in six in-patient hospital stays will include at least one bill from an out-of-network provider.

Let's take a look at the impact on health insurance payers.

What about emergent care?

One of the most commonly recognized forms of surprise billing is in emergent care situations. In these cases, the patient has no control over the ambulance provider, where they receive care, or whether the provider is in or out of the payer's network.

The IFR stipulates that normally covered emergency services, including air ambulance, must be covered without prior authorization at in-network rates. In other words at no more than the in-network cost-sharing amounts.

The Act outlines the reimbursement amounts that must be paid to out-of-network providers, and also defines arbitration procedures for dispute resolution.

Additional guidance will also be coming from HHS regarding independent dispute resolution (IDR) entities and the IDR process in September, so stay tuned!
Let's clarify in-network vs out-of-network coverage for non-emergent care.

This section of the IFR addresses out-of-network provider bills for non-emergent services provided at in-network facilities.

For example, a patient might have a surgery scheduled at an in-network facility, but they receive care from an out-of-network surgical assistant or anesthesiologist, etc.

The IFR requires advance notice, pricing disclosure and patient consent for any services to be provided by out-of-network providers under certain conditions. It also prevents balance billing outright for specific non-emergent services including pathology, radiology, anesthesiology, and other services from out-of-network providers at in-network facilities.

The IFR states that out-of-network cost-sharing calculations are based on the "recognized amount" for such services. Unless the All-Payer Model Agreement or a state law applies, the recognized amount is the lesser of the qualifying payment amount (QPA) or the amount billed by the provider or facility.

The QPA can be determined in several ways and calculating it may be complicated. Under the IFR, the QPA is generally the median of the contracted rates of the plan or issuer for the item or service in the geographic region.

What about out-of-network provider reimbursement disputes?
Out-of-network reimbursements are either based on rates that the plan and provider have agreed to, or they can negotiate the rates. If neither of these applies, and there's a dispute, the payer or the provider can choose to enter into arbitration. This process is known as independent dispute resolution or IDR.

Disputes between payers and providers essentially follow these timelines:
  • The Payer Must Send the Payment, or a Denial for Out-of-Network Services, Within 30 Days of Receiving the Bill
  • The Provider Must Accept or Challenge the Payment or Denial
  • Any Challenge Initiates a 30 Day Open Negotiation Period for the Parties to Settle
  • After the 30 Day Open Negotiation Period Ends, Either Party Can Choose to Enter Into IDR. Additional guidance addressing the IDR process and IDR entities are expected to be issued in September.

This is where H.H.C. Group can help!
You have a limited time window to take strategic action. Once you enter into the IDR process, the fate of the claim is essentially in the hands of the arbiter. Arbitration costs are on the horizon.

H.H.C. uses this 30 day open negotiation period to settle the claim for you, quickly and on your terms.

Our team of expert negotiators can help you manage your risk by avoiding arbitration costs and potentially unfavorable decisions by the IDR entity. We help you manage your claims risks on your terms.

Let H.H.C. sort it all out for you. We'll come up with the right claims negotiation strategy to fit your needs.

Using bulldog tenacity to reduce medical claims!
Why do health insurance payer organizations partner with H.H.C. Group?

At H.H.C. we are a group of legal and clinical experts laser-focused on negotiating the best possible billing outcome for you.

We provide significantly reduced claims costs, exceptional quality of service, and super-fast turnaround times for our clients. That's why health insurance payers partner with H.H.C.

Let H.H.C. take a bite out of your medical claims!

Why wait? Get in touch with one of our claims specialists today to discuss your customized surprise billing solution. Call 301-960-7092, or schedule a meeting today.