In most cases, balance billing does not come as a surprise, as both patients and providers are aware of potential out-of-network charges on top of the payment made by a respective insurance company. In such matters, balance billing is legal, provided that this awareness is documented. However, sometimes neither patients nor healthcare providers realize that an insurer will not pay for a service in full. For example, a patient may get service at an in-network hospital by an out-of-network physician, or a healthcare provider may not know that his/her participation contract with a specific benefit plan has been terminated.
Any balance billing conducted without a patient’s awareness of it is called “surprise billing”.
On September 30, 2021, the government issued an interim final rule with comment period, entitled “Requirements Related to Surprise Billing; Part II” under the No Surprises Act. It implements protective measures against surprise medical bills, such as an independent dispute resolution process, good faith estimates for uninsured (or self-pay) individuals, the patient-provider dispute resolution process, and expanded rights to external review. The final rule determines the following aspects:
• Balance billing is prohibited for emergency services (that is, you cannot bill a patient for an outstanding amount after an emergency visit, even if a rendering anesthesiologist is out-of-network with a patient’s plan).
• Patient cost-sharing for emergency services and certain non-emergency services provided at an in-network facility cannot be higher than if such services were provided by an in-network provider, and any cost-sharing obligation must be based on in-network provider rates.
• Out-of-network (OON) charges for items or services provided by an OON provider at an in-network facility are prohibited unless certain notice and consent are given by a patient.
• Uninsured individuals must not receive a bill for an amount that exceeds a good faith estimate (an estimated balanced amount to be billed by a healthcare provider after the visit – it must be mentioned to a patient before the services are rendered).
Providers who violate any of the above-mentioned postulates risk facing a liability. So here comes a question: what are the Dos and Don’ts of balance billing? Let us take a look at what our billing experts have to say.
1) DO check your patients’ eligibility and your participation status with his/her plan.
Most surprise bills occur when services are rendered out-of-network. To protect yourself from underpayments and unnecessary collection processes you should ensure that a benefit plan will pay the charged amount in full according to contractual obligations.
2) DO check your contractual provisions with insurance payers.
Many insurance carriers, such 1199, prohibit healthcare providers from collecting any monetary liability from its enrolled members. This often applies even to deductibles and coinsurance.
More importantly, Medicaid beneficiaries cannot be “billed” in New York under any circumstances, except for cases where there is a written consent given by a patient to the provider prior to rendering a procedure.
3) DO check your local legislation.
Not all states have implemented measures against balance billing not involving the cases mentioned above. Provisions related to this issue are active in the following US states:
• New Hampshire
• New Jersey
• New Mexico
• New York
• North Carolina
• Rhode Island
• West Virginia
4) DO prepare a disclosure statement regarding the patient protections against balance billing.
Each facility provider, hospital, and ASC is required to make publicly available, including on its website and to each patient covered by a commercial policy, a disclosure regarding the patient protections against balance billing. Such notice must be provided individually to commercially insured patients no later than the time a bill is sent to the patient or a claim is submitted to the insurance.
5) DO calculate good faith estimates for the services that you provide most frequently, and save them in a single document.
Whether you often see uninsured patients or not, it is a good idea to calculate approximate charges for the majority of services that you can offer to such patients before they make an appointment.
1) Don’t attempt to balance bill a qualified Medicare/Medicaid beneficiary.
If you accept Medicare/Medicaid patients, you must accept reimbursement from Medicare or Medicaid as payment in full. If you attempt to bill any Medicare or Medicaid patient for the remaining balance, this would violate the terms of your Medicare Provider Agreement, unless it is a circumstance mentioned above.
2) Don’t leave insurance underpayments as they are.
Our experience shows that many surprise bills result from an incorrect claim processing by a carrier. If you see an underpaid claim, first you would need to contact the payer and ask for the reason of underpayment. No matter what it is – initiate a reconsideration process or submit a corrected claim first before billing your patient.
3) Don’t keep your outstanding balance records in your mind, or even in a notebook – sign up for our billing service and try WCH iSmart.
Did you know that there’s an all-in-one tool that allows you to keep track of your patients, their visits, and financial liabilities? Our clients enjoy using WCH iSmart – a real-time practice management platform. This online portal allows you to quickly locate your patients’ outstanding balance and send a bill to them.
Interested? Contact us!