Help Avoid Surprise Billing to Clients

It is no secret that the healthcare sector is flourishing, and future expansion is anticipated. Thus, the billing procedure is essential to the ongoing operation of any hospital or midwifery office. Creating billing claims and submitting them to insurance companies are both involved. This guarantees that the hospital or midwife's office is paid the appropriate sum for the services they render to patients. Keeping your patients informed about their bills is a difficulty that all midwives encounter.

When receiving emergency treatment, non-emergency care from out-of-network midwives at in-network institutions, or air ambulance services from out-of-network providers as of January 1, 2022, patients will have new billing protections. Emergency services must continue to be covered without any prior authorization and regardless of whether a midwife or birth center is in-network thanks to new regulations intended to protect consumers.

Before, if patients had health insurance and sought treatment from an out-of-network practitioner, their health plan would typically not cover the whole out-of-pocket expense. Many ended up paying more as a result than they would have if they had seen an in-network provider. In an emergency, when customers might not be able to select the supplier, this is very typical.

A client may receive treatment from out-of-network providers at a facility even if they go there. In many instances, the out-of-network providers may charge patients the difference between the fees they billed and what was covered by their health plan. This practice is called balance billing. A surprise bill is a balance that appears out of the blue.

The No Surprises Act under title I and Transparency under title II are just two of the many measures in the Consolidated Appropriations Act of 2021 that assist shield customers from unexpected bills. This law was passed on December 27, 2020. Learn more about consumer protections, anticipating prices to avoid unpleasant surprises, and what happens when disputes over payment develop after obtaining medical care.

What are the new protections if I have health insurance?
If you get health coverage through your employer, the Health Insurance Marketplace®, or an individual health insurance plan you purchase directly from an insurance company, these new rules will:

• Ban surprise bills for emergency services, even if you get them out-of-network and without approval beforehand (prior authorization).
• Ban out-of-network cost-sharing (like coinsurance or copayments) for all emergency and some non-emergency services. You can’t be charged more than in-network cost-sharing for these services, and any cost-sharing you pay counts towards your deductible and maximum out-of-pocket limits for the policy year.
• Ban out-of-network charges and balance bills for supplemental care (like anesthesiology or radiology) by out-of-network providers who work at certain in-network facilities (like a hospital or ambulatory surgical center).
• Require that health care providers and facilities give you an easy-to-understand notice explaining that getting care out-of-network could be more expensive, and your options to avoid balance bills. You’re not required to sign this notice or get care out-of-network.

If you have a health insurance plan with an out-of-network benefit, like a Preferred Provider Organization (PPO), you can choose to go to an out-of-network provider. But you can’t be billed more than in-network cost-sharing amounts for items or services provided by an out-of-network provider at in-network facilities unless you consent to get care out-of-network by signing a notice and consent form.

Certain services at an in-network hospital or ambulatory surgical center
When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers can bill you is your plan's in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can't balance bill you and may not ask you to give up your protections not to be balance billed.

Are there exceptions to these protections?
These protections don’t apply in all situations.

• If you have a vision- or dental-only plan, these new billing protections generally don’t apply to services these plans cover. But if you have a health plan that includes dental or vision benefits, these protections could apply to any dental or vision services covered by your health plan.
• The balance billing protections generally don’t apply to ground ambulance services.
• Some health insurance coverage programs already have protections against high medical bills. You’re already protected against surprise medical billing if you have coverage through Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care, or TRICARE. These new rules don’t apply to these programs.

Policies are crucial since they outline what is and isn't permitted within the healthcare industry. They will make sure that all actions conducted within the healthcare provider are done so that the organization may reach its goals if they are created properly. They can assist in determining the type of work they do, the types of jobs they won't do, and the values they uphold. Policies are created to improve the situation of the healthcare sector. When properly followed, it will assure productivity and prevent problems that could affect patients as well as healthcare providers. If you feel wronged or in an unjust situation. Feel free to visit the CMS website at https://www.cms.gov/nosurprises/consumers

Reference
Ending surprise medical bills. CMS. (n.d.). Retrieved January 2, 2023, from https://www.cms.gov/nosurprises/Ending-Surprise-Medical-Bills