October 21, 2022
Medical debts are often due because of accidents or sudden illnesses. Many times, consumers are not informed about the cost of medical treatment before they occur and have limited or no ability to shop around. As a result, when patients receive a surprise medical bill, they are unaware if they actually received the billed treatment, if the insurance company covers the amount, if the correct amount is billed, and if the amount is already paid or partially paid.
The NSA (No Surprise Act) was introduced as a part of the CAA (Consolidated Appropriations Act) of 2021. It addresses the surprise medical billing issues faced by patients at the federal level. Thus, the Departments of Health and Human Services, Labor, and Treasury are tasked to issue guidance and regulations to implement several provisions successfully.
In this guide, we will explain what a surprise medical bill means, new requirements and prohibitions for surprise billing, applications of the federal protection for surprise bills, and the AMA toolkit for NSA implementation by hospitals and medical practices.
They are unexpected medical bills that result from services patients receive from a healthcare facility that they did not know was out of network until they were billed for it. Patients may be liable for the difference between the out-of-network costs and what their health insurance paid. It is called "balance billing". The surprise medical bill could be for services like anesthesia or lab tests.
Most medical practices prefer getting medical billing services from a professional medical billing company to avoid inconveniences, avoid breaking the rules and lift the burden of coding and billing.
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The protections will apply to most surprise bills in certain settings for specific types of rendered care services.
The NSA covers services rendered by out-of-network providers at in-network hospitals and other facilities. Many times, doctors working at hospitals do not bill the hospital. Instead, they bill separately and are not required to be part of the same healthcare plan networks. As cited by KFA (Kaiser Family Foundation), the federal government estimated that 1.8 million of 11.1 million (16%) private insured patients who stay in non-emergency facilities each year have at least one out-of-network claim.
NSA defines that emergency services also include post-stabilization services provided in a hospital after an emergency visit. After stabilization, a patient is considered to be in an emergency until a doctor determines that they can safely travel to another in-network medical facility using non-medical transportation. If such a facility is available and accepts the transfer, there will be no further unreasonable burdens. As per KFA, federal government estimates show, 4.1 million emergency visits result in hospital admission, and out of these, and in 16% of these admissions, at least one is an out-of-network claim.
Surprise billing protections are available for most emergency services. These include those rendered in urgent care centers, freestanding emergency departments, and emergency rooms of hospitals licensed to provide emergency care. Federal law applies to both emergency and non-emergency air ambulance transport. However, it does not apply to a ground ambulance. According to KFA, the federal government estimated that each year there are 39.7 million emergency encounters at medical facilities; of these, 18% have at least one out-of-network claim.
If you want to reduce the number of in-person hospital visits, integrate a telehealth system to take your practice virtually anywhere. CareCloud also introduced digital health solutions to help your practice transition to the next generation of healthcare. Besides, our revenue cycle management (RCM) solution helps your practice have healthy financial health.
The NSA and its implementing rules base a method to determine the patient's cost-sharing in these out-of-network situations. When state law doesn't establish a provider payment method, the NSA creates an IDR (independent dispute resolution), an arbitration system for provider payments.
The AMA (American Medical Association) toolkit focuses only on three operational issues that physicians must address immediately to comply with the new requirements.
Part I: Non-emergency Services at In-network Hospitals - notice and consent requirements allow out-of-network doctors to balance their bills when seeing patients in network medical facilities. Also, there are situations where such consent cannot or is not possible.
Part II: Freestanding Emergency Departments or Post-stabilization Care at Hospitals and Emergency Services - rules that apply to emergency care, mainly when out-of-network providers can balance bills for care following an out-of-network emergency.
Part III: GFEs (Good Faith Estimates) for the Uninsured or Self-pay Patient - obligations to provide a GFE of provider charges for scheduled self-pay or uninsured patients, as well as dispute resolution for any bills significantly exceeding the GFE.
This guide walked you through the new prohibitions and requirements for surprise billing. We also discussed what a surprise medical bill means and the federal protection application for surprise bills. Besides, we introduced you to the AMA toolkit for NSA implementation by hospitals and medical practices.
As stated by the NSA, you can stay within the boundaries by outsourcing your medical billing to an expert medical billing company like CareCloud. Besides, we also offer telehealth solution, digital health, RCM solution, etc.