Medical billing has faced many changes in recent years by the legislative authority regarding reimbursement rates and out-of-network services. According to some reports, Americans were disturbed by the high billing over the treatment. Many people were even reluctant to get medical assistance due to fear of surprise bills. Medical debt is increasing due to these surprise bills, and people, after the treatment, get another shock in the face of large accounts, even more than their whole life savings.
To protect the people from this drastic situation, the US government imposed a law called the “No Surprise Act.” This act is implemented considering getting out-of-network services during emergencies. As of Jan 01, 2022, insurers and healthcare providers cannot send costly bills to patients for out-of-network treatments and medical procedures. In this article, we will learn about everything about this act, along with the challenges faced by the patients due to the implementation of this act.
Understanding of in-network and out-of-network services
Suppose the person has private insurance and gets medical services from a healthcare provider with a contract with his health insurance company. In that case, we call this service an in-network service. But in any case, if a person gets medical services from a healthcare provider without a contract with his insurer, it is called out-of-network service. The healthcare provider sends the medical bill directly to the patient, and he charges according to his value. Patients can get large or heavy accounts for medical services, and their private insurers never accept this type of claim. In short, getting out-of-network service can significantly burden the patient financially.
What is the “No Surprise Act”?
On Jan 01, 2022, the US government implemented this law. According to it, no healthcare provider can send the bill to the patient for out–of–network services without negotiating with the patient. Healthcare providers must inform the patient about the price and deal with him. Healthcare providers should also deal with the insurer to cover these expenses. This step has changed the business model for healthcare providers. Generally, if a person comes to an in-network institute but the doctor is unavailable for treatment, the hospital directs the patient to an out-of-network doctor without knowing him. Patients get the bill after the treatment, and they know that out-of-network service has been given.
Positive outcomes for the medical billing system
This law has many positive impacts on the medical billing system, and was also necessary to make the required amendments. Below are a few benefits described;
Transparency
Healthcare providers should inform the patient about everything before providing the out-of-network service. They are also supposed to negotiate the price for treatment. This increases the transparency in the system, and everything remains apparent to the patient. Every information regarding the in-network and out-of-network is disclosed to the patient along with the financial burden information. This helps people to make immediate decisions about their care and treatment procedures. There will also be no dispute among the patients and insurers regarding the reimbursement rates.
Surprise billing protection
This act has protected people from the surprise bills they get after emergency-based medical services. For instance, an emergency case of an accident comes in the hospital, and the in-network doctor is unavailable. Before this act, hospitals do not inform the patient or his attendants about the out-of-network service before giving the treatment. After providing the service, hospitals handed over the hefty bill to him. No surprise act stopped this uncertainty and forced the doctors to provide information before the treatment, and if the patient is willing to proceed, they can provide treatment, and the insurers will also claim its bills.
Arbitration System
An arbitration system is formed under this act to resolve the dispute between healthcare providers and insurance companies. It will ensure that healthcare providers get a suitable amount for the services given to the patients in emergencies. Under this law, healthcare providers can’t charge more than the estimated reasonable amount for the treatment procedure and medical services. This system will also ensure that insurers are not asked to pay extra and will also take care of the rights of insurance companies.
Challenges for patient
High ambulatory service cost
In case if government ambulance service is unavailable in the area and people call for an ambulance, it will be an out-of-network service. As ambulance service does not come under this act, it will always be challenging for the patients to pay the high cost. We are talking about the by-road ambulance service. It is said that it is like booking an Uber with a high price. The Government should consider this problem and include it under the “No Surprise Act”‘.
Limited Scope
This act is applicable in emergencies only. If a person wants to go to out-of-network physicians, he has to face massive expenses, which limits the medical rights of Americans to get treatment from the best doctors.
Suppose a patient visits an in-network physician, and the physician asks him to have some medical tests. He goes to the nearer laboratory, which is out-of-network. Then, the person again has to face costly trials and financial burdens.
Disputes among health providers and insurer
Disputes have come to notice among healthcare providers and insurance companies regarding the reimbursement prices for specific treatments after the implementation of this law. These disputes go on for an extended period, and in the meantime, the patient is always at stake in the financial debt due to no outcome of the argument for a long time. Government should regulate the prices for medical treatments and services and impose those prices on the healthcare providers and insurance companies to avoid increasing disputes.
Conclusion
In the case of out-of-network medical services, patients have to face expensive bills from healthcare providers. This created a sense of hesitation among the Americans to get medical services, and to cope with this situation, the US government implemented a “No Surprise Act.” According to it, healthcare providers can only send the bills to the patients for out-of-network services if they negotiate them. It is also stressed that insurers will accept the claim for these services. This law increases transparency, avoids surprise billing, and imposes an arbitration system. An Arbitrator will resolve the issue regarding the reimbursement prices among the insurers and healthcare providers. But only some challenges remain for the patients due to its limited scope. Patients can’t benefit from this law except in emergencies. Ambulatory services do not come under this law. Government should think about these challenges to provide benefits to the patients.
