The current practice of “balance billing” allows health care providers to charge the insured employee for the balance of a medical bill when an insurance company does not pay the full amount. Surprise bills can be the result of an insured unknowingly receiving medical services from an out of network provider. These unexpected bills can be tens of thousands of dollars and financially devastating to the insured. However, change is on the horizon.
SHRM reports in the article, Relief from Surprise Medical Billing Becomes Law, that the Continuing Appropriations Act, 2021, signed into law at the end of 2020, included a revised version of the bipartisan No Surprises Act. This act aims to put the brakes on unscheduled “surprise” out-of-network health care charges, such as care received at an out-of-network emergency room, an air ambulance transport, or from an out-of-network assistant surgeon at an in-network hospital. Most of the new requirements take effect with plan years beginning January 1, 2022.
Some of the provisions affecting employer-sponsored group plans and self-insured plans are:
- Ambulances (air, not ground)
- Ancillary Services
- Arbitration
- Disclosures
At Healthcare Horizons, we are advising our self-insured clients to do three things:
- Hold your TPA responsible for meaningful negotiation with out-of-network providers.
- The balance billing mindset may not go away immediately, and carriers acting as negotiators should establish a patient advocacy program to actively support their insureds.
- Conduct annual audits to ensure that patients’ cost share is based on comparable in-network rates.
The Difference is in Knowing.
To learn more about our approach to healthcare claims auditing or out-of-network provider fee negotiation services, visit Healthcare Horizons, or reach out to us at hhadmin@healthcarehorizons.com.
Randy King is president of Healthcare Horizons Consulting Group, Inc. The company is one of the nation’s leading healthcare claims auditing firms, focused exclusively on self-insured employers since 1999. Healthcare Horizons has recovered millions of dollars for its clients through auditing and air ambulance negotiations for some of the world’s largest employers.