Surprise Medical Billing Banned Starting in 2022

Take these actions now to maximize reimbursement and avoid billing disruptions.

Take these actions now to maximize reimbursement and avoid billing disruptions.

One unpleasant surprise will soon be a thing of the past. Congress recently passed the No Surprises Act, banning surprise medical billing. Given that two thirds of Americans worry about being able to afford an unexpected medical bill, many patients will celebrate this new legislation. Providers may not be as eager to embrace the new law, which may decrease their reimbursement. According to the American Medical Association, some providers may not have the resources to negotiate fair compensation for their services.

Surprise medical bills occur when insured patients unknowingly receive care from an out-of-network provider. In a medical emergency, patients typically cannot choose the emergency room, physicians, or ambulance providers, so they may end up at an out-of-network facility or being treated at an in-network hospital by out-of-network providers. Patients receiving scheduled care at an in-network hospital with an in-network surgeon may receive a surprise bill if the other providers treating them (such as anesthesiologists or radiologists) don’t participate in their health plan’s network. In either situation, patients cannot choose the provider or determine that provider’s network status. Patients wind up paying a higher percentage of allowed charges (co-pay) for out-of-network services, and they receive a “balance bill.” 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 covering the remaining amount.

Surprise billing is common and costly. For people in large employer plans, 18 percent of emergency visits and 16 percent of in-network hospital stays had at least one out-of-network charge associated with the care in 2017. Most of the surprise bills come from either anesthesiologists or surgical assistants — who are typically not chosen by patients. A large analysis of 347,356 surgical episodes involving commercially insured patients who underwent elective surgery with in-network primary surgeons and facilities revealed that 20 percent of episodes resulted in out-of-network charges. Out-of-network bills were associated with surgical assistants in 37 percent of the episodes, with average potential balance bills of $3,633. Out-of-network bills were associated with anesthesiologists in 37 percent of the episodes, with average potential balance bills of $1,219.

Starting in 2022, the No Surprises Act will prohibit balance billing and limit consumer charges to the in-network cost-sharing amount. Patients won’t receive surprise balance bills when they seek emergency care, are transported by an air ambulance, or receive nonemergency care at an in-network hospital but are unknowingly treated by an out-of-network physician or laboratory. Insured patients will pay only the deductibles and copayment amounts that they would pay under the in-network terms of their insurance plans.

This means that, beginning in 2022, healthcare organizations won’t be allowed to bill patients for the difference between in-network and out-of-network charges. Instead, hospitals will have to work with health plans to establish fair prices for out-of-network services. Health plans and hospitals that cannot agree on a payment rate will use an outside arbiter to decide. The arbiter would determine a fair amount based, in part, on what other doctors and hospitals are typically paid for similar services. This may result in lower reimbursement for services delivered by out-of-network providers. 

Most Providers Should Participate in Most of Your Contracted Health Plans

What can you do to avoid having to negotiate prices and accept lower reimbursement for out-of-network services? The simple answer is to ensure that most, if not all, of your providers are in-network and represented accurately with your contracted health plans.

Assess provider participation status in all contracted health plans. Conduct par/non-par analyses to identify providers who are either not enrolled or enrolled inaccurately with your organization’s contracted health plans. Your goal should be to ensure that all eligible providers are enrolled with all contracted health plans at their respective billable locations prior to treating patients. Participation does not end once providers are initially enrolled. Be aware of the re-enrollment/revalidation timeframes of each health plan so that providers remain in-network.

Properly enroll all eligible providers with all contracted health plans. Pay close attention to inpatient specialties, such as radiologists, pathologists, emergency medicine, anesthesiologists, and surgical assistants to ensure they’re included in all your health plan networks. Their contracting may not necessarily require individual providers to enroll, as they are not listed in member directories. But their billable information (Tax ID numbers, provider listing, places of service, etc.) must be on file with your contracted health plans.

Verify provider enrollment status before scheduling patients. When scheduling patients for elective procedures and non-emergency care, confirm that all providers involved in the patient’s treatment are enrolled in the patient’s health plan. Obtain real-time participation status updates, monitor enrollment via your enrollment software’s enterprise-wide dashboards, and ensure your scheduling team has access to the real-time data.

Expecting schedulers to call and verify provider enrollment every time a patient schedules a procedure is not realistic. Provider enrollment software simplifies the verification of provider enrollment status by giving schedulers real-time access to providers’ enrollment information. If a provider is not participating with a particular health plan or product line, they should not be treating members with that insurance. Schedulers should not schedule patients with those health plans or product lines until the provider is participating, or they should re-direct the patients to a provider who is currently participating.

TractManager’s Provider Enrollment solution streamlines, automates, and accelerates the enrollment process for government and commercial health plans. Our technology-enabled provider enrollment solution conducts par/non-par analyses; provides real-time participation updates; and reduces enrollment-related claim edits and denials through dynamic data validation. To learn more about our Provider Enrollment Solution, check out the OnDemand webinar titled The Digital Transformation of Provider Enrollment.


Allyson Schiff

Senior Director, Strategy & Growth, Provider Management

Allyson Schiff joined Newport Credentialing Solutions in 2009 and joined TractManager when Newport was acquired in 2018.


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