3 Ways to Stay Out of Hot Water for 'Surprise' Medical Bills

January 3, 2017 by Antonio Arias, MBA, CHBME

Topics: Meaningful Use Stage 2, Practice Management, Medical Billing Company

When it comes to hot-button healthcare issues, the problematic prevalence of balance billing is near the top of the list. Consumers have been decrying the practice for decades – and regulators are (finally) raising a flag at the high amount of ‘surprise’ medical bills being sent to patients around the country.

As most medical billing professionals already know, patients can be caught off guard when they receive statements requiring them to cover the difference between the cost of a given service and the amount an insurer has agreed to reimburse for that service. In instances in which patients receive care from an out-of-network physician, the charges can be (in the eyes of patients) excessively or unnecessarily high.

Increasingly, it’s hard to argue with patients’ perspective. Among providers, high rates of ‘surprise’ medical bills are often blamed on the growth of high-deductible insurance plans built around small networks of health-care providers but those ‘narrow networks’ may not be the real issue: A study recently published in The New England Journal of Medicine found that many patients are being hit with big out-of-network bills even when they take care to go to hospitals that their insurers considered in-network.

According the research, ‘surprise’ balance billing occurred in about 22 percent of emergency departments visits covered by one large commercial insurance company alone. Further research backs up the prominence of the problem: A recent Health Affairs study saw surprise medical bills in 14% of outpatient ER visits and 9% of elective inpatient admissions.

So what’s being done about the problem? In February 2016, the HHS released a final rule aimed at reducing surprise medical bills: The rule provides for a portion of an out-of-network provider’s fees to count toward the patient’s annual cost-sharing requirements when the service is provided at an in-network facility. (That’s an important piece of the puzzle: The Health Affairs study found that out-of-network anesthesiologists were used in 17% of elective inpatient admissions where surprise medical bills were found.)

In addition, lawmakers in New Jersey have pushed for legislation that would cap the amount out-of-network doctors and hospitals are paid for emergency treatment and a Florida senator has advocated for an FTC investigation into deceptive billing practices.

As proposals like those play out, providers are wise to protect themselves from any present or future consequences related to balance billing. While it can be difficult for doctors to resolve the problem at a macro level, there’s much they can do on a small-scale basis to protect patients from financial harm.

Initiate the Cost Conversation: Doctors are often hesitant to discuss care costs with patients, but the time has come to get transparent. By opening up an honest dialogue about in-network and out-of-network care costs, doctors can ensure that balance bills aren’t a surprise.

Invest Effort in Staying In-Network: When it comes to referrals, patients are often trusting their primary care providers – wisely or not – to match them with an in-network specialist. Take that trust seriously by tasking your staff with checking provider status.

Think Smart About Codes & Charges: Wherever possible, use preventative care codes, prescribe generic medications, and coordinate wisely with physicians within your same hospitalist networks. Ultimately, a little concern and common-sense cooperation can go a long way to keeping your patients from paying unnecessarily high amounts.


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