Healthcare Revenue Cycle Compliance
Billing/RCM

Best Practices in Patient Eligibility and Benefits Verification

Written by: Melvin Miller, Chief Operating Officer




With rising consumerism, patients have increasing responsibility for payments. The growth of high deductible health plans (HDHPs) is a clear indicator of this trend. It is, therefore, important to clearly understand the patient's responsibility for payments upfront and determine coverage.  


This article highlights the importance of patient eligibility and benefits verification.


What is patient eligibility and benefits verification?


A healthcare practice must verify a patient's coverage for medical services and determine their responsibility for payments. Through the patient eligibility and benefits verification process, physician practices can confirm the coverage offered by the health plan and copayments, deductibles, and co-insurance with the health plan. 


Verification of eligibility promotes the collection of the coverage status and reduces the likelihood of claims getting denied. It enables healthcare providers to collect payments from patients proactively and prevents delays in cash realization.


Information to be provided for patient eligibility and benefits verification


One of the fundamental components of the front-office tasks is to collect the patient details upfront and enable the verification of benefits by insurance verifiers.


Healthcare providers must train staff members on the insurance verification processes. Efficient processing reduces the likelihood of denials and accelerates the cash flow cycle.


Electronic and manual eligibility verification processes


Most payers have made available interfaces to check eligibility online. By verifying eligibility electronically before the scheduled patient appointment, you will be able to:

  • Get accurate information about the patient's insurance status and understand the benefits of the health plan.
  • Determine if you must collect a co-pay at the time of service.
  • Update insurance details.
  • Get patients to update primary care physician details.

Sometimes, it may be necessary to call the payer with questions related to prior authorization requirements or clarify some eligibility and benefits elements.


Timeliness of eligibility checks


Healthcare providers must check eligibility at least 48 hours before the visit. Should this not be possible, it can be done in real-time during check-in before the treatment. Timely eligibility checks help you reduce claim rejections and denials. Most electronic health records and revenue cycle management systems have electronic eligibility checking functionality. By verifying the patient's coverage before care delivery, your practice will be able to reduce denials and improve revenue realization.


Importance of process documentation


The needs of your practice are unique. A substance use support clinic has very different eligibility verification requirements from a hospital or radiology clinic. Hence, each institution must create specific eligibility and benefits verification workflows. All your team members need to collaborate effectively and ensure efficient completion of all steps.


Checklist for eligibility verification


The following are some of the best practices for the patient eligibility and benefits verification process.

  • Check if the plan is active.
  • Always quiz the patient about any impending or recent insurance changes.
  • Check if the patient has multiple insurances – primary, secondary and tertiary. Ensure that the patient has updated the Coordination of Benefits (COB) with each payer.
  • As a significant percentage of the population in the United States is aging, verify the Medicare coverage for patients who are above 65 years of age.
  • Understand if you need prior authorization or a referral for the specific medical service. If referrals or authorizations are needed, please obtain them and update the revenue cycle system.
  • Confirm if the patient's policy covers the procedure.
  • Some plans may stipulate the number of visits and time frame in which medical services can be delivered and have a ceiling on the benefit limits. The front office must obtain these details.
  • Specific services such as behavioral and mental health, substance abuse, and addiction may require a call to the insurance company. You may not be aware of these requirements and must refer to payer-specific guidelines.
  • Collect the payments for deductibles, copayments, and co-insurance based on the policy details. Pursuing patient collections can be tedious, and you must collect as much upfront as stipulated.
  • Collect additional information.

Social determinants of health are becoming an essential element of care delivery and promote healthcare equity and access. Characteristics such as race, gender, ethnicity, date of birth, preferred language, etc., are essential for Meaningful Use reporting. These characteristics are also crucial for health equity studies.


Outsourcing eligibility and benefits verification processes

 

An outsourced service provider can help you carry out eligibility and benefits verification processes. Their training processes help you get expert workers at reduced costs and reduce the workload on your revenue cycle team. Some of the benefits of outsourcing are:

  • Freeing up your staff's time to focus on other patient experience improvement and revenue cycle functions.
  • Speeding up time to care delivery.
  • Reducing denials and accelerated cash flow.
  • Reducing costs through labor rate arbitrage.
  • Well maintained policies and procedures.
  • Shifting the focus to denial prevention by reducing the number of eligibility and benefits related denials.

Eligibility and benefits verification company competencies


Efficient eligibility and benefits verification processes are essential for your organization's financial well-being. The process also accounts for the highest component of claim denials. You need to learn from each denial and constantly improve. Retain a company which can provide seasoned revenue cycle workers who can support your front-office staff with eligibility and benefits verification processes as well as comprehensive revenue cycle solutions to reduce costs and improve efficiency.


Additional Resources:

  • Medical Billing Wholesalers - https://www.medicalbillingwholesalers.com
    _________________________________________________________
    Melvin Miller is an experienced Chief Operating Officer with a demonstrated history of working in the healthcare industry for over 15 years, Satish, a.k.a. Melvin, has experience in team building, business development, Healthcare Information Technology (HIT), revenue cycle process training, US. Health Insurance Portability and Accountability Act (HIPAA), and Healthcare Management.
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Healthcare Revenue Cycle Compliance
Billing/RCM

Key Revenue Cycle Trends for 2022 and Beyond

Written by: Melvin Miller, COO




Tech, investments, efficiency, patient experience, underpayment recovery, and coding automation are some of the themes that will drive the revenue cycle market momentum in 2022 and beyond. Coming at the back-end of a long period of adversity due to COVID-19 and an already challenging economic environment for hospitals and healthcare systems, we see a new wave of consolidation, invention, and innovation. In this paper, we discuss some of the trends experienced in health care.


TIGHTENING PROFIT MARGINS – A PANDEMIC RAVAGED REVENUE CYCLE TO BOTTOM OUT.


With hospitals operating on extremely tight margins, projecting cash flow and the ability to extract the maximum out of the revenue cycle is more critical than ever before. This will drive key technology and process innovation as revenue cycle leaders and managers strive to improve business outcomes.


Now, let’s look at the broad trends in each of the major revenue cycle processes.


Patient Access and Experience


Patient experience is now one of the key issues impacting the healthcare industry. There is a huge information deficit in the area of patient payments.


Patients question “How much should I pay from my pocket?” The answer has been surprisingly difficult to find. Patients must get quick and easy access to information about services performed and corresponding charges; the amount expected to be paid by their insurance company; and the out-of-pocket expenses they are expected to bear. It is important to include the aspect of the No Surprises Act, which complicates the situation for both providers and patients.


We anticipate patient access and experience to improve with new technologies that can project the costs they need to bear, improved omnichannel information availability, and improved payment plans. Patient financial services will go through a much-needed overhaul.


Prior-Authorization and Eligibility Verification


While great tech exists for information interchange, prior authorization and eligibility verification tech adoption have lagged because of a lack of standardized documentation and information exchange protocols. With clearinghouses now modernizing, there is new hope for API-driven information exchanges.


Autonomous Coding


Automation tech is seeing increasing adoption, and there is a general perception that coding, billing, and accounts receivable problems will be solved through automation. Artificial Intelligence, Machine Learning, and Robotic Process Automation technologies provide great promise to lower labor costs. Medical coding is becoming data-driven and autonomous with improved standardization through ICD-11 and a better combination of virtual scribing, Universal Medical Language Systems (UMLS), OCR, and natural language processing (NLP). While these are still early days, coding tech is yet to prove effective in finding discharges not fully coded (DNFC) and arresting revenue leakage.


A/R, Denial Management, and Appeals Filing

Accounts Receivable (A/R) status has moved from calls to portals. We see increasing relevance for chatbots using conversational artificial intelligence (AI) in A/R and denial management filing. Data structures can now power customized appeals filing as well.

Focus on the Front-End

Most revenue cycle leaders agree that they need to solve revenue cycle issues in the front-end rather than elongate the cycle and wait to address them in the back end. They recognize that they need to link prior authorization, revenue integrity, clinical documentation improvement, and denial management to accelerate their revenue cycle. The ability to quickly identify denial issues, determine root causes, and develop solutions to reduce these denials through an iterative model that focuses on denial prevention is considered the key to addressing revenue cycle issues.

Underpayment and Analytics

The Hospital revenue cycle is fraught with underpayment issues. Contract analysis and underpayment identification can help arrest underpayments. As the shift to more branded, national healthcare practices happens, performance analytics becomes a critical business function. Practice-specific analytics using standard measures and Key Performance Indicators or KPIs will enable accurate views of performance and drive corrective action.

Unprecedented Financial Activity – Private Equity (PE), IPOs, Mega-mergers, and More

“It’s like Woodstock,” as some revenue cycle dealmakers are saying. The role of private equity in healthcare, in general, and the revenue cycle business, in particular, has increased to an unprecedented level.

  • Entry of the big boys. The big boys, i.e., the large PE firms have made strategic investments in revenue cycle assets.
  • Technology-led investments. Some of the themes that PE firms are investing in include focused revenue cycle service providers and niche technology companies such as autonomous coding, patient experience, prior authorization, and large-scale offshore providers.
  • Investments in revenue cycle aggregators. It seems like if a company’s resume says revenue cycle, it is likely to attract many valuations. Further, larger companies choose to hit the primary market through an initial public offering. We are seeing increasing consolidation of revenue cycle service providers as well.
  • Provider side consolidation. There is an increasing amount of investment in consolidation on the provider side. The push to provide a branded healthcare experience through nationwide chains is driving investments in areas such as urgent care, behavioral/mental health, wellness-focused treatments, home healthcare franchises, etc.

In 2022, we anticipate the continuance of these trends and mega-mergers will be more of a norm than an aberration.

Telehealth Adoption

Spurred on by the pandemic, telehealth adoption is increasing. Not only does this mean a lower cost of care, but it also requires the adoption of new processes for patient monitoring and managing the revenue cycle.

Remote Working

The COVID-19 necessitated revenue cycle team members to adopt work-from-home models. It also required operations managers to be flexible and adopt technologies to monitor revenue cycle performance. We anticipate that hospitals and healthcare systems will look at remote working as the new normal and encourage a significant percentage of their workforce to work remotely.

Labor Shortage and Outsourcing

There is an acute shortage of qualified revenue cycle staff. Many community hospitals are concerned about the community’s response to outsourcing and offshoring strategies they adopt. At this time of rising hospital expenses and reducing revenues due to declining reimbursements, outsourcing, offshoring, and automation can help them contain costs and sustain profitability. If using a U.S. based company that offshores the majority of their work, have you checked with legal counsel regarding how this type of business associate can be held accountable under U.S. laws (such as HIPAA, False Claims Act, etc.)

Conclusion

There has never been a better time to be in healthcare – and these are the most challenging times as well. Both in terms of economic activity and innovation, 2022 is likely to set a scorching pace. Whether you are a healthcare system, revenue cycle services provider, or technology solutions provider, this year will force you to think innovatively, build new delivery frameworks, and create the revenue cycle of the future.

Additional Resources:

_________________________________________________________

Melvin Miller is an experienced Chief Operating Officer with a demonstrated history of working in the healthcare industry for over 15 years, Satish, a.k.a. Melvin, has experience in team building, business development, Healthcare Information Technology (HIT), revenue cycle process training, US. Health Insurance Portability and Accountability Act (HIPAA), and Healthcare Management.
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Healthcare Revenue Cycle Compliance
Billing/RCM

Update on No Surprises Act 2022

Written by: Joanne Byron, BS, LPN, CCA, CHA, CHCO, CHBS, CHCM, CIFHA, CMDP, COCAS, CORCM, OHCC, ICDCT-CM/PCS




As a result of the 2021 Consolidated Appropriations Act, several No Surprises Billing Act regulations went into effect on January 1, 2022, for providers, facilities and air ambulance services. The information below is not legal or consulting advice, but is provided as education and offers links to additional resources.


Starting January 1, 2022, the No Surprises Act protects people covered under group and individual health plans from receiving surprise medical bills when they receive most emergency services, non-emergency services from out-of-network providers at in-network facilities, and services from out-of-network air ambulance service providers.


This article is a follow up to the August 17, 2021, Sending “Surprise” Medical Bills to Patients? Think Again blog post related to the January 1, 2022, implementation of the Interim Final Rule (IFR) of the No Surprises Act. The new law provides consumers with federal protection from unexpected out-of-network medical bills.


Out-of-network charges are common in emergency care, where consumers don’t necessarily have a choice in where they go or who provides their care. These charges can also arise during non-emergency hospitalizations, where multiple providers may be involved in care. Even if a hospital participates in a patient’s insurance plan, specific providers, such as anesthesiologists or radiologists, may not. Consumers may have no idea that they’re getting care from out-of-network providers and no say in it either.


A news release from November 22, 2021, entitled New HHS Report Highlights How the No Surprises Act Will Prevent Surprise Medical Bills Faced by Millions of Americans highlights that millions of Americans with private health insurance experience some kind of surprise medical billing. The report states that surprise medical bills are relatively common among privately-insured patients and can average more than $1,200 for services provided by anesthesiologists, $2,600 for surgical assistants, and $750 for childbirth-related care.


The No Surprises Act establishes an independent dispute resolution process for payment disputes between plans and providers, and provides new dispute resolution opportunities for uninsured and self-pay individuals when they receive a medical bill that is substantially greater than the good faith estimate they got from the provider. These don’t apply to people with coverage through programs like Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care, or TRICARE. These programs have other protections against high medical bills.


Well, 2022 is here and it is time for EMS, hospitals and other emergency service departments to comply with the No Surprises Act. This can get complicated when meshing this Act with the Emergency Medical Treatment and Labor Act (EMTALA) imposing restrictions on obtaining patient financial or insurance status. The question – how can providers best manage EMTALA, Crisis Standards of Care (CSC), the pandemic and adhere to the new No Surprises Act?


First, it is important to have providers and other staff involved in patient care understand some of the more critical aspects of EMTALA. EMTALA requires Medicare-participating hospitals with emergency departments to screen and treat the emergency medical conditions of patients in a non-discriminatory manner to anyone, regardless of their ability to pay, insurance status, national origin, race, creed or color.


EMTALA is triggered whenever a patient presents to the hospital campus, not just the physical space of the ED but within 250 yards of the hospital. Patients who present to a hospital parking lot, sidewalks, and adjacent medical buildings are mandated to undergo EMTALA screening and stabilization. The provisions of EMTALA apply to all individuals (not just Medicare beneficiaries) who attempt to gain access to a hospital for emergency care.


The Centers for Medicare and Medicaid Services (CMS) defines a dedicated emergency department as “a specially equipped and staffed area of the hospital used a significant portion of the time for initial evaluation and treatment of outpatients for emergency medical conditions.”


EMTALA requires hospitals with emergency departments to provide a medical screening examination to any individual who comes to the emergency department and requests such an examination, and prohibits hospitals with emergency departments from refusing to examine or treat individuals with an emergency medical condition. The term “hospital” includes critical access hospitals.


This means, for example, that hospital-based outpatient clinics not equipped to handle medical emergencies are not obligated under EMTALA and can simply refer patients to a nearby emergency department for care. Typically, outpatient physician offices that do not have resources to stabilize critically ill patients are not required to perform a medical screening examination or stabilization before transferring the patient to an ED. In other words, patients who are part of an outpatient encounter are exempt from these EMTALA regulations. However, the No Surprises Act can still apply to services rendered by your provider.


When a patient has a health insurance Marketplace or individual health plan, the new Act applies as follows (this is a summary):

  • Bans surprise bills for most emergency services, even if rendered out-of-network and without approval beforehand (prior authorization);
  • Bans out-of-network cost-sharing (like out-of-network coinsurance or copayments) for most emergency and some non-emergency services. Patients can’t be charged more than in-network cost-sharing for these services;
  • Bans out-of-network charges and balance bills for certain additional services (like anesthesiology or radiology) furnished by out-of-network providers as part of a patient’s visit to an in-network facility; and
  • Requires that health care providers and facilities give patients an easy-to-understand notice explaining the applicable billing protections, who to contact for concerns that a provider or facility has violated the protections, and that patient consent is required to waive billing protections (i.e., patient must receive notice of and consent to being balance billed by an out-of-network provider).

Patient has no insurance? In most cases, a good faith estimate of how much the care will cost needs to be provided to the self-pay patient prior to rendering such care.


State Billing Laws Still Apply


The No Surprises Act supplements state surprise billing laws; it does not supersede them.


This new Act instead creates a “floor” for consumer protections against surprise bills from out-of-network providers and related higher cost-sharing responsibility for patients. So as a general matter, as long as a state’s surprise billing law provides at least the same level of consumer protections against surprise bills and higher cost-sharing as does the No Surprises Act and its implementing regulations, the state law generally will apply.


For example, if your state operates its own patient-provider dispute resolution process that determines appropriate payment rates for self-pay consumers and Health and Human Services (HHS) has determined that the state’s process meets or exceeds the minimum requirements under the federal patient-provider dispute resolution process, then HHS will defer to the state process and would not accept such disputes into the federal process.


Is Your Organization Prepared?


A violation of the No Surprises Act may result in a state enforcement action or federal civil monetary penalties of up to $10,000 per violation.


Know the plans your organization is in-network with – create a “grid” or listing for reference and keep it updated.


Know your state laws and when Federal laws supersede state rules. Contact your risk attorney through your malpractice insurance company for guidance which is obtained through no additional cost (part of the service you get when paying the insurance premium).


Identify eligible cases. The Act applies to post-stabilization care at out-of-network facilities until a patient can be safely transferred to an in-network facility. Nonparticipating providers and facilities may balance bill for post stabilization services only if all of the following conditions have been met, such as when the attending emergency physician or treating provider determines that the beneficiary, enrollee or participant:

  1. Can travel using non-medical or non-emergency medical transportation to an available participating provider or facility located within a reasonable travel distance, taking into account the individual’s medical condition; and
  2. Is in a condition to receive notice and provide informed consent.
  3. The nonparticipating provider or facility provides the beneficiary, enrollee or participant with a written notice and obtains consent that includes certain content and within a specific timeframe and format outlined in regulation and guidance.
  4. The provider or facility satisfies any additional state law requirements

Make sure revenue cycle workforce members understand EMTALA compliance and can identify out-of-network situations or when the patient is self-pay. 


Implement an efficient and compliant method of providing a good faith estimate. The good faith estimate must include expected charges for the items or services that are reasonably expected to be provided in conjunction with the primary item or service, including items or services that may be provided by other providers and facilities.

  • From January 1, 2022, through December 31, 2022, HHS will exercise its enforcement discretion in situations where a good faith estimate provided to an uninsured (or self-pay) individual does not include expected charges from other providers and facilities that are involved in the individual’s care.

Download the CMS Model Notice and Consent forms.


Your revenue cycle department should have someone already trained to negotiate with out-of-network payers. The first step is to actively negotiate with insurance the highest reimbursement possible since you can no longer balance bill the patient. Are you utilizing Advanced Explanation of Benefits in plain language to provide good faith estimates? Track results – are your processes working? 


Identifying No Balance Billing for Out-of-Network Emergency Service Definitions


Emergency services

With respect to an emergency medical condition, appropriate medical screening including ancillary services, medical examination and treatment required to stabilize the patient, and certain post-stabilization services associated with the emergency medical condition that are covered under the plan or coverage, unless certain notice and consent and other criteria are met.


Emergency medical condition

A medical condition, including a mental health condition or substance use disorder, manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in a condition that places the health of the individual in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ.


Nonparticipating emergency facility

An emergency department of a hospital or an independent freestanding emergency department (or a hospital with respect to post stabilization services) that does not have a contractual relationship directly or indirectly with a group health plan or group or individual health insurance coverage, with respect to the furnishing of an item or service under the plan or coverage.


Nonparticipating provider

Any physician or other health care provider who does not have a contractual relationship directly or indirectly with a group health plan or group or individual health insurance coverage, with respect to the furnishing of an item or service under the plan or coverage.


Participating health care facility

Any health care facility that has a contractual relationship directly or indirectly with a group health plan or health insurance issuer offering group or individual health insurance coverage, with respect to the furnishing of an item or service under the plan or coverage.


Definitions Related to Continuity of Care When Provider Network Status Changes

Continuing care patient - an individual who:

  1. is undergoing a course of treatment for a serious and complex condition from the provider or facility;
  2. is undergoing a course of institutional or inpatient care from the provider or facility;
  3. is scheduled to undergo non-elective surgery from the provider, including receipt of postoperative care with respect to such surgery;
  4. is pregnant and undergoing a course of treatment for the pregnancy from the provider or facility; or
  5. was determined to be terminally ill and is receiving treatment for such illness from the provider or facility.

Serious and complex condition definition:

  1. in the case of an acute illness, a condition that is serious enough to require specialized medical treatment to avoid the reasonable possibility of death or permanent harm; or
  2. in the case of a chronic illness or condition, a condition that

a) is life-threatening, degenerative, potentially disabling or congenital; and

b) requires specialized medical treatment over a prolonged period of time.


Questions?

Send any questions about the provider requirements and provider enforcement to:

provider_enforcement@cms.hhs.gov


Resources

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Telehealth
Telehealth

How Geriatric Care Will Change in the New Normal

Written by Sophie Johnson




The healthcare industry has been transformed by the pandemic, and one part of healthcare that was thrust into the spotlight over the last 16 months is geriatrics. The Centers for Disease Control and Prevention (CDC) states that older adults were more at risk of coronavirus complications, which put them at a higher likelihood of being hospitalized. This has changed how the healthcare sector has responded to seniors, and it will continue to shape how geriatric healthcare will continue in the new normal.


How COVID Affected Geriatric Care


The elderly were affected more severely by the pandemic because they were already a vulnerable population to begin with. Beyond preventing and treating the virus itself, healthcare centers also had to mitigate the adverse effects of extended isolation for older patients. Other restrictions also prevented seniors from getting the physical activity needed to maintain their health, leading to a faster-deteriorating state.

The beginning of the pandemic presented the greatest challenge for geriatric healthcare workers since there were physical distancing protocols in place. Geriatric care shifted to telehealth to meet the needs of older adults. This presented many challenges, the most pertinent one being how to increase the digital literacy of older people, as it became the main way to access resources and contact persons. As these challenges continued, caregivers and family members have had to give more support to seniors to ensure that their needs would be met and, ultimately, prevent hospitalization.

How Geriatric Care Will Change in the New Normal


The way care has changed during COVID-19 will likely continue into the new normal, but there will certainly be some changes in the preventive measures taken to ensure older adults are resilient, healthy, and safe.

Telehealth will grow

According to Pew Research, only about 40% of people aged 74 to 91 years use the internet. However, this is drastically changing. Doctors are seeing more and more virtual visits from older people as part of their practice. And with the ability to access doctors online becoming much easier now, senior patients may be inclined to make more visits, which will significantly improve their overall health.

One of our previous blogs, How Telehealth Is Being Used to Treat Mental Health, discussed how telehealth has also already improved mental health for older people through online therapy, emergency services, and remote monitoring programs, all of which are likely to become the norm in the new normal.

People will have more than one physician

Older people will likely be seeing teams of doctors rather than just one dedicated physician. It is a more efficient and cost-effective way of accommodating patients and for those patients to have their needs met without long waits. And with easier access to more doctors, seeing several specialists is now easier than before.

Coverage plans will become a priority

Apart from getting vaccinated, the CDC also recommends seniors take extra preventive measures to protect themselves from contracting COVID-19. However, individual efforts such as wearing a mask and a healthy lifestyle may no longer be sufficient, especially for older people who are at risk of suffering from other conditions.

This increased awareness in the new normal will see a rise in older adults investing in medical plans. Fortunately, the healthcare industry has long anticipated this, with many different plans available that cater to specific needs. Kelsey Care Advantage outlines the different packages available, some focusing on dental care while others put a premium on cardiovascular conditions. Older adults may even prefer medical coverage that includes medication and fitness benefits. Being prepared in this manner will allow older people to feel more secure should any health concerns come about in the future, COVID or otherwise.

For additional timely and relevant healthcare related information like this, please check out our other blog articles and access all of our course offerings at AIHC.

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Healthcare Revenue Cycle Compliance
Billing/RCM

Sending “Surprise” Medical Bills to Patients? Think Again

Written By: Joanne Byron, BS, LPN, CCA, CHA, CHCO, CHBS, CHCM, CIFHA, CMDP, COCAS, CORCM, OHCC, ICDCT-CM/PCS




Government Announces the No Surprises Act to Protect Patients


"Requirements Related to Surprise Billing; Part I" is an interim final rule related to Title I (the No Surprises Act) targeting health care providers with the purpose of restricting excessive out of pocket costs to consumers from surprise billing and balance billing. Balance billing, when a provider charges a patient the remainder of what their insurance does not pay, is currently prohibited in both Medicare and Medicaid. This rule will extend similar protections to Americans insured through employer-sponsored and commercial health plans. 


Most of us love surprises, but not when it comes to devasting surprise medical bills.


Tackling surprise billing has become a government priority, according to the press release made July 1, 2021, from Department of Health and Human Services (DHHS) which states that two-thirds of all bankruptcies filed in the United States are tied to medical expenses. The press release refers to a citation used by DHHS from a report made by CNBC. Researchers estimate that 1 of every 6 emergency room visits and inpatient hospital stays involve care from at least one out-of-network provider, resulting in surprise medical bills.


Surprise billing happens when people get care from providers outside of their health plan's network unknowingly. This can occur in both emergency and non-emergency care situations, but you must agree, we are most vulnerable during circumstances related to emergency medical treatment.


Surprise Billing Curtailed – My Experience in 2021

Case in point:  I was diagnosed with a rare condition and referred to a specialist this year. The first available appointment with the specialist was in 3 months. Finally, during my visit with the specialist (who was worth waiting for, by the way), it was determined that part of my plan of care would include a special form of physical therapy. The specialist placed the order in Epic and instructed me to see a very specific physical therapist highly skilled in treating people with my rare diagnosis. The appointment for therapy was made for me as I left the specialist’s office. When I went home, I logged into my AARP Medicare Advantage UHC plan to find that the therapist was not in network with my insurance; none of the therapists in that clinic were. I called my insurance, got a list of in-network providers, searched to find 3 that offer treatment for my condition, checked each therapy clinic with the Better Business Bureau (BBB) and only selected those with an A+ rating. Then, I called each one and had to leave a voicemail. I finally started therapy within a few days for a $35 copay. If I had not performed my own due-diligence, there would have definitely been out-of-network surprise bills! 


The frustration of working full time, having to wait for 3 months to see the specialist to get a treatment plan, being referred to an out of network therapist and having to lose more time from work to research and locate an in-network provider just added to my stressful situation.


Not everyone has my background as a nurse, coder, compliance officer, documentation specialist and auditor. I can see how many patients would have ended up with huge medical bills because they trusted the doctor to make in-network referrals. And even with my background and experience, if my situation was related to an emergency, I would not have been able to circumvent the “surprise bill” situation.


Implementation of the Interim Final Rule is January 2022

The regulations are generally applicable to group health plans and health insurance issuers for plan and policy years beginning on or after January 1, 2022. The HHS-only regulations that apply to health care providers, facilities, and providers of air ambulance services are applicable beginning on January 1, 2022. Upon implementation of the Interim Final rule, patients will be removed from the billing negotiation process between the insurer and the provider.  Among other provisions, the interim final:

  • Requires certain health care providers and facilities to make publicly available, post on a public website, and provide to individuals a one-page notice about:
    • The requirements and prohibitions applicable to the provider or facility under Public Health Service Act sections 2799B-1 and 2799B-2 and their implementing regulations.
    • Any applicable state balance billing limitations or prohibitions.
    • How to contact appropriate state and federal agencies if someone believes the provider or facility has violated the requirements described in the notice.
  • Bans surprise billing for emergency services.
    • Emergency services, regardless of where they are provided, must be treated on an in-network basis without requirements for prior authorization.
  • Bans high out-of-network cost-sharing for emergency and non-emergency services.
    • Patient cost-sharing, such as co-insurance or a deductible, cannot be higher than if such services were provided by an in-network doctor, and any coinsurance or deductible must be based on in-network provider rates.
  • Bans out-of-network charges for ancillary care (like an anesthesiologist or assistant surgeon) at an in-network facility in all circumstances.
  • Bans other out-of-network charges without advance notice.
    • Health care providers and facilities must provide patients with a plain-language consumer notice explaining that patient consent is required to receive care on an out-of-network basis before that provider can bill at the higher out-of-network rate.

In order to learn important details about this interim final rule Read the Fact Sheet. Also, obtain online, on-demand formal training and get certified in Revenue Cycle Management, which is recommended for all RCM supervisors, billing company managers/owners and chart auditors. Updates on the implementation of this important No Surprises Act is included in the Revenue Cycle Management course as details develop.


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