Balanced billing is crushing Americans’ pocketbooks – here’s how you can avoid it

By John Staub, Remodel Health Brand Development Manager

Imagine doing your due diligence and selecting a hospital and provider in your insurance network to have your next medical procedure, only to get a bill several weeks later saying you owe thousands of dollars more than you initially expected. It’s because someone who provided care to you, whether it’s an anesthesiologist, x-ray technician or someone else, during your stay was not considered to be in-network with your insurance company. You did your research, so why are you on the hook for this outlandishly – sometimes financially crushing – large medical bill?

These “balanced bills” are one of the leading causes of medical debt, which is the #1 cause of bankruptcy in the U.S. In fact, most medical debt bankruptcies are filed by those who have insurance. Under a new law, known as the No Surprises Act, patients are not responsible for these balanced bills, meaning the difference – or “balance” – between the expected in-network costs versus the actual out-of-network costs. While this new law is a step in the right direction, many Americans don’t know the added benefits of the new law.

Take advantage of these five benefits.

The No Surprises Act is aimed at helping Americans through incredibly difficult periods in their healthcare journey. Take a look at the benefits this new law offers individuals, and why it’s necessary now more than ever.

Held harmless.

Being “held harmless” for medical bills means Americans are no longer liable for out-of-network costs in situations where patients do not have the ability to choose an in-network provider. For example, an ambulance service or physician that is out-of-network would not be directly charged to the individual, rather it would be charged to their insurance.

No balance billing.

Should a patient be able to choose between an in-network or an out-of-network provider, but still select to go out-of-network, the out-of-network provider is required to submit notice of their network status, including all estimated costs associated, at least three days prior to the scheduled service. This removes the surprise of those charges to the individual by requiring the provider to gain consent after costs are shown.

Kept out of the middle.

The discrepancies between provider charges and insurance coverage would arise in the case of surprise bills, resulting in the individual being placed directly in between those two parties – where little advocacy and support could occur.

Legislators created a framework that takes the individuals out of the middle to help resolve this issue, making them only accountable to their in-network liability. Coined the Independent Dispute Resolution (IDR), the new process gives providers and insurers the means to satisfy the disagreement without requiring the inclusion of the individual. According to the Centers for Medicare and Medicaid Services (CMS), “Beginning January 1, 2022, if you’re uninsured or you pay for health care bills yourself (don’t have your claims submitted to your health plan), health care providers and facilities must provide you with an estimate of expected charges before you get an item or service.” This is known as a good faith estimate. Patients may be able to dispute the bill if it is at least $400 above the good faith estimate.

Transition of care.

It’s not uncommon to see changes happen between networks and providers, such as rotating hospitals and doctors in-networks, and these changes happen largely without any formal warning to the consumer. Better protections for individuals are in place with this new law, because it requires the insurance company to fully disclose when there is a modification to coverages for active provider relationships. Additionally, the individual can appeal in-network cost continuation for any acute care requirements.

Transparency.

Arguably one of the most important benefits of the No Surprises Act is the transparency it gives to patients, as it requires the provider to fully describe to the individual their planned treatments, expected costs, as well as their current status and the individual’s insurance network. As members of the healthcare industry, we hope this allows Americans to become better consumers of their own healthcare. It also helps promote better competition between providers to generate higher levels of value and quality to their patients.

Evaluating the options.

Health insurance is expensive and confusing, but you shouldn’t be stuck paying more than you anticipate just because someone within your in-network facility happens to be out-of-network with your insurance provider. Employers and employees can make more informed healthcare choices if they walk through a complete health benefits analysis and side-by-side comparisons of all options on the market.

The No Surprises Act puts consumers more in control of their health benefits than ever before and gives Americans a fighting chance when the odds are against them. Now, it’s no longer a surprise.

About the Author

John Staub serves as Brand Development Manager for Remodel Health, an HR service used by universities and colleges across the country that provides innovative health benefits solutions to employers and employees alike. As a national thought leader and expert in the health benefits field, John brings passion and knowledge to the benefits industry.