Now Is the Time to Prepare for Billing Rule Changes
Friday, April 2nd, 2021

Healthcare providers will be subject to a new surprise billing regulation starting next year, which prohibits providers from billing customers more than in-network cost-sharing for out-of-network services and creates an arbitration mechanism to settle unexplained out-of-network costs.

The No Surprises Act, which was enacted as part of the omnibus budget bill last year, is a response to unexpected medical bills. The proposed guidelines for out-of-network charges would have a major impact on healthcare services.

As an example, if a patient is treated at an in-network hospital but an out-of-network anesthesiologist helps with care, the patient will only be responsible for the in-network cost-sharing rate for the facility, under the new regulation.

Until proceeding to litigation, the payer and the contractor will have 30 days to reach an agreement. The “final-bid” negotiation procedure would require suppliers and payers to both make an offer to an autonomous third party to settle the surprise billing conflict. After weighing median in-network negotiated costs, patient acuity, and other considerations, the third-party arbitrator would pick one of the deals as the definitive bid.

Providers and payers must also recognize their business preparation, customer engagement activities, and negotiating policy to comply with the legislation.

Adding or exploiting analytics tools to push plans to prevent balance billing scenarios is part of organizational preparation for the surprise billing rule.

In terms of customer outreach, distributors and payers should consider extending out-of-network prevention techniques to avoid surprise billing scenarios and developing a consumer education plan to increase consumer awareness of network and benefit options.

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This update is provided by CareOptimize. We provide healthcare management consulting services and products, managed care solutions, value-based expertise, Nextgen EHR utilities, MIPS consulting, and more. CareOptimize has helped numerous healthcare organizations succeed for more than a decade. For more information, please call 855.937.8475.