Surprise Medical Billing and Some States Are Ahead of Feds

surprise medical billing
Source: Medical News Today

In the past few years, surprise medical billing has gotten a lot of attention. Many patients are billed with thousands of dollars for healthcare services they reinvest by the medical providers.

Surprise medical billing services as is obvious from the name are the medical bills that come to the surprise of the healthcare consumers. It is a type of unexpected charge which the patient was not expecting and which is neither covered by the insurance. It is charged on the pretext that the patient getting the services has received medical services from an out-of-network physician so the payment has to be made to another medical organization or physician. Although some insurance companies cover the parts of the out-of-network bill in most cases, the patient is asked to pay for the difference. The situation is more troubling when even these patients come to the emergency of a hospital they are not notified upfront that an out-of-network provider would be involved to take care. However, the patients only come to know when they are demanded to pay an out-of-network bill.

Currently, there are over 25 states in the US that have made legislation to protect patients from surprise medical billing or out-of-network bills. These states are also protecting healthcare consumers from commercial insurance providers.  Most of the self-insurance programs are regulated by feds but various states have gone ahead of the federal legislation.

Both the main parties in the House of Representatives have denounced the occurrence of surprise billing and consider it a big problem for healthcare consumers. However, long before federal legislation comes to liberate consumers from surprise billing; many states have already enacted the law to protect patients.

The practice has been around for the past few decades and the instances of surprise billing were increasing over time. Until recently many states have passed the law to fix this long pending issue but fewer states have fully implemented it.

What is surprise billing?

Surprise billing is when the patients don’t know that the services, they are receiving are not covered by the medical insurance provider and have to pay for it out of their pocket.

Some government and healthcare stakeholders have taken notice of surprise billing. Some state governments have passed the law that ensures that patients are not held responsible for out-of-network billing services. So far, twenty-five states in the US have banned surprise billing and made it illegal for healthcare providers to send such bills to patients. This is usually for the emergency care services that the patient receives in the hospital.

Increased number of surprise billing

The JANA Internal Medicine said that the surprise medical billing practice is getting out of hand and increasing day by day. Many patients who have private insurance end up getting g surprise billing even after visiting a hospital that is in-network. According to research out of 3, every 2 adults worry about surprise billing. Surprise medical billing has increased by millions of dollars and increasing every year.

Who is the in-network provider?

An in-network provider is someone who has a contract with a healthcare plan. These services are usually provided at a lower price as the provider aims to get more patients because of that. On the other hand, an out-network provider is someone who does not have a contract with a specific health plan and hence free to charge whatever price they think is correct.

Surprise billing vs. balance billing

A surprise billing, sometimes also known as balance billing usually arises when the patient is in the state of emergency and needs medical services right away and therefore does not have enough time to choose between an in-network and out-network provider and go with the first option they have in hand. This leads to surprise billing which is not fair for the customers and can result in pushing them into bankruptcy.

The practice of balance billing is not new and has been around since the 1980s. Some providers charge a higher fee for their services which leads to the problem of surprise medical billing as these providers are not ready to charge the same as their fellow providers. And although the state has passed laws against surprise billing g there is still a lack of a more comprehensive and holistic law to counter the problem of balance billing. It should cover services related to both emergency and non-emergency departments, health maintenance organizations, and Preferred Provider Organizations, and help patients from getting into any financial liability that was out of their hands.

The biggest challenge for lawmakers right now is to come up with a solution that both the insurers and medical providers agree upon. The insurance carriers do not want to pay more for services and the medical providers do not want to receive less reimbursement or otherwise, they won’t provide the services. This issue has hindered the progress of the lawmakers from making any improvement in the laws against surprise billing in states like Georgia, Virginia, Washington, and Pennsylvania.

No Surprise Act

The government released the new No Surprise Act law for the year 2021 which protects customers from receiving unexpected medical billing. The law has made it mandatory for private medical billers to cover the cost of surprise bills in their network plan. The law also states that no prior authorization is required to cover surprise billing. The law has many aspects, and it has brought receive to the patients worried about surprise billing.

Surprise medical billing was in practice for decades and was a serious issue for the healthcare sector. Various states have passed laws to stop this big issue of healthcare consumers and they have even gone ahead of the feds.


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