Prevent Surprise Billing Through an Efficient Provider Enrollment Process

When it comes to medical bills, no one likes surprises.


Surprise medical bills occur when patients are treated by out-of-network providers under unavoidable circumstances. For example, patients having surgery at an in-network hospital performed by an in-network surgeon, whom they chose, may be surprised to discover that their anesthesiologistwhom they did not choose, was out-of-network.  

According to three national studies, approximately 1 in 5 emergency department (ED) visits involved care from an out-of-network provider that could result in a surprise out-of-network bill if not prohibited by state or federal law.  

Three U.S. House of Representatives committees (Energy & Commerce, Education & Labor, and Ways Means) are working on policies to protect consumers against medical surprise billing. The Ways Means committee introduced its proposed legislation in February 2020  

Starting in 2022, the Consumer Protections Against Surprise Medical Bills Act would prohibit balance billing and limit consumer charges to the in-network cost-sharing amount. Balance billing occurs when a patient’s health insurance company pays an out-of-network physician less than the amount the physician charges for the care, leaving the patient responsible for the remaining amount. Under this new act, the financial burden on the patient would not exceed their in-network cost-sharing amount  

What does this mean for patients?

 You will not be held responsible for more than you agreed to — no surprise billing.
The circumstances may be unavoidable, but the charges will no longer exceed the in-network cost-sharing amount agreed upon between the patient and their insurance plan. Cost sharing includes the deductible, co-insurance, and copayments which will vary depending on the patient’s coverage plan. This bill will cap out-of-network fees to the total cost-sharing amount.

Example: Deductible up to $2,500
Co-Insurance 20% to 80% up to 20,000 – then 100% plan
Patient Responsibility Total Cost Share – $2,500 + $20,000 = $22,500
Surprise Bill capped at $22,500

Patients would receive better, more transparent information about provider networks and anticipated costs and would be protected during network changes. Specifically, patients would receive: 

  • A true and honest cost estimate—called an Advance Explanation of Benefitsthat describes which providers will deliver their treatment, the cost of services, and provider network status.  
  • More timely bills. Patients would noreceive bills long after the services were provided. 
  • Continuity of care when networks change. Patients undergoing treatment at the time their provider leaves their network will have up to 90 days to transition to another provider 

How Can Health Systems Prevent Surprise Billing?
In most cases, care from an out-of-network provider may be unavoidable. Having said that, it can be significantly limited bimplementing an efficient, effective provider onboarding, credentialing, and enrollment platform. Furthermore, health systems will prevent claim denials by having providers properly enrolled and by submitting accurate provider information.  

To enroll providers efficiently and accuratelyhealth systems must: 

  • Quickly submit provider enrollment applications or rosters (in delegated credentialing model). This requires compiling required information, submitting the appropriate documents to payers, and following up with payers to ensure that provider information is listed correctly. Data entry errors or inconsistencies may result in compromised enrollment and misinformation regarding the participation status of providers 
  • Regularly monitor provider data. The provider management team needs to continually check and update provider and facility demographic information to ensure that payers have current, accurate data. 
  • Conduct a participating and nonparticipating (par/non-par) analysis to identify providers who are not enrolled with health plans. A par/non-par analysis validates the participating status of each provider across all health plans, locations, and Tax IDs. The goal should be to have 100 percent of health system’s providers enrolled with all contracted health plans.  
  • Submit claims to payers promptly so patients receive timely bills.  

By taking these steps, health systems can mitigate out-of-network claims and ensure a positive experience for both providers and patients. Happy patients and providers are more likely to remain loyal to a health system. Satisfied providers will be more likely to refer patients to other providers, and satisfied patients will recommend services to their family and friends 

TractManager’s credentialing and enrollment solution and experts automate and manage your entire enrollment process—from data entry and QA maintenance to par/non-par analyses, and payer application submissions and follow-up. When you partner with TractManager, surprise billings become a thing of the past.   




Anna Arutyunyan

Vice President, CVO, Provider Management

Anna has extensive experience in the development and implementation of full-scope credentialing programs.


Our Solutions Automate and Streamline Your Provider Management Processes.

Learn how our integrated MediTract CLM, Provider Onboarding, and Physician Analytics capabilities deliver measurable results to your healthcare organization.

Share This