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Avoid Surprises by Staying Abreast of Surprise Billing

Analysis  |  By Amanda Norris  
   August 18, 2022

CMS regulations and accompanying surprise billing updates are changing faster than revenue cycle leaders can keep up.

The surprise billing ban was put in place by CMS to protect patients from receiving unforeseen bills for out-of-network and emergency services after receiving treatment. While beneficial for patients, organizations have long shared their distain of the burden this causes for revenue cycle staff.

Revenue cycle leaders need to stay informed of this requirement in order to be compliant and ensure a positive patient financial experience. Review the most recent surprise billing stories from HealthLeaders.

This month, a New York surgeon's bid against the No Surprises Act for being unconstitutional was tossed as the federal law was upheld.

A federal judge denied a New York doctor's lawsuit against the No Surprises Act, dismissing the request for a preliminary injunction and ruling that the law is constitutional.

U.S. District Judge Ann Donnelly rejected surgeon Daniel Haller's injunction to blow the law, which was filed on December 31, 2021, the day before the No Surprises Act took effect.

Haller and his private practice, which performs procedures on patients who are admitted after an emergency department visit, alleged in the complaint that the law is unconstitutional and deprives providers the right to be paid a reasonable payment for their services due to the independent dispute resolution process.

Also this month, the Medical Group Management Association (MGMA) requested HHS and CMS to give providers at least six months' notice before enforcing any additional requirements for the No Surprises Act.

Several aspects of the surprise billing mandate went into effect on January 1 of this year, including federal protections against balance billing, uninsured and self-pay good faith estimate requirements (GFE), continuity of care protections, and provider directory requirements.

While the policies have been beneficial for patients, MGMA says the requirements have created administrative burden for providers as the interim final rules were published with minimal time before implementation.

In late July, the Workgroup for Electronic Data Interchange (WEDI) also released a letter to HHS regarding the No Surprises Act.

The workgroup takes aim at the GFE convening provider/facility provision saying it has significant concerns with how this part of the act can be successfully adopted by two providers.

In the letter, WEDI recommends HHS consider an initial phase of the GFE requirement initiated by a patient request, extend the enforcement discretion period, identify standards-based solutions, and phase in the one- and three-day time requirement.

WEDI says these issues should be expeditiously addressed by HHS to ensure successful implementation of the legislative provisions of the act.

"While the No Surprises Act includes much needed consumer protections against catastrophic 'surprise' bills, it also includes challenging data exchange provisions such as the convening provider/facility requirement," stated Charles Stellar, WEDI president and CEO.

Also in July, a survey showed that surprises bills continue to be sprung on patients, even with a federal ban in place, with one in five adults receiving an unexpected medical charge this year.

Yet 20% of respondents in the Morning Consult survey say they or their family have been charged unexpectedly, with another one in five billed after being treated by an out-of-network provider at an in-network facility.

The bills have been especially costly in some cases, as 22% of respondents say their charges were over $1,000.

Unexpected charges haven't just been an issue after the fact. The survey found about one in four adults delayed or skipped medical care because they were concerned with receiving a surprise bill. Emergency room care suffered the most in this facet, with 14% of respondents saying they did not seek care, while another 14% say they hesitated but ended up receiving care.

“While the No Surprises Act includes much needed consumer protections against catastrophic 'surprise' bills, it also includes challenging data exchange provisions such as the convening provider/facility requirement.”

Amanda Norris is the Revenue Cycle Editor for HealthLeaders.

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