When it comes to healthcare expenses, people often have to spend without knowing the cost upfront. Until recently, patients and their families had virtually no way of knowing their expected out-of-pocket costs. Thankfully, the “No Surprises Act,” which came into effect in January this year, is all set to fix this system and enable patients to make choices based on what they can afford.

What is surprise billing?

When people go to an in-network hospital, they may owe certain out-of-pocket costs, such as a copayment or co-insurance. They also have to pay the entire bill if they receive care from an out-of-network provider, such as a doctor or laboratory, resulting in high charges.

In surprise billing, you can’t control who is involved in your care; you are unexpectedly treated by an out-of-network provider.

What does “out-of-network” include?

Any provider and facility that hasn’t signed a contract with your health plan fall into the “out-of-network” provider category. They may bill you for the total amount charged for a service or the difference between what your plan agreed to pay. The costs can sometimes be more than in-network costs for the same service.

How will the “No Surprises Act” protect you?

As the name indicates, this act prohibits surprise bills and allows patients to make choices based on what they can afford. The healthcare providers will be required to provide patients with a good-faith estimate of the expected charges for all services that they might need. This would include the expense of services offered by all health care providers involved in the care, irrespective of whether they are part of the same practice or health system or not.

Those with health insurance can request insurance plan pricing estimates, including available discounts.

Let’s elaborate on this with the help of an example.

Let’s say a person wants to have elbow surgery. So, before the surgery, the healthcare provider will have to furnish the estimated charges for the surgery center, drugs, imaging services, the anesthesiologist, and any follow-up visits. By comparing the estimates, the patient can make an informed choice and choose the services with the lowest costs.

Highlights of the Act

• It applies to most surprise bills for emergency care and non-emergency services provided at in-network facilities.
• The providers cannot charge patients more than the applicable in-network cost-sharing amount.
• It will be mandatory for the providers to determine the patient’s insurance status before submitting the surprise out-of-network bill to their health plan.
• Private health plans will have to cover out-of-network claims.
• The act also establishes a process for determining the payment amount for surprise medical bills.
• Patients can appeal disputes over coverage of surprise medical bills to an external reviewer.

How will this act benefit healthcare providers?

While there may be some challenges for the healthcare providers as this act comes into effect, it also presents opportunities to understand patients and create better relationships.

Some benefits for the healthcare providers include:

• Providers will be able to avoid unpaid medical bills.
• They can improve revenue cycle performance and reduce bad debts.
• They can provide better experiences to their patients.
• Providers can identify lower-cost options to provide better care at lower costs.

Wrap Up

The “No Surprises Act” aims to serve as a consumer protection remedy, but you may not experience a considerable drop in the healthcare expenses for your family this year. However, as things will be simplified over time and medical expenses will become easier to understand, people will be more empowered to make more informed choices.