No Surprises Act Requires More Transparent Medical Billing

September 9th, 2022 - Find-A-Code
Categories:   Compliance   Billing  

No Surprises Act Requires More Transparent Medical Billing

Congress passed the No Surprises Act as part of the 2021 Consolidated Appropriations Act. No Surprises was fully implemented as of the start of this year. With it now being the law of the land, healthcare providers are legally obligated to provide more transparent medical billing so that patients do not receive surprise bills for out-of-network care or in-network care provided by an out-of-network clinician.

As a medical billing or coding specialist, how your job is impacted by the law depends on how your employer's business is structured. Needless to say, running afoul of the law would not be good for your career. You owe it to yourself to be familiar with the No Surprises Act and how it affects billing and coding.

The Original Problem

So, what was the original problem the No Surprises Act was designed to solve? Patients receiving unexpected medical bills after receiving out-of-network care they either were not aware of or had no control over. In times past, such an incident would lead to an insurance company only paying the in-network cost, leaving the patient to cover the rest out of pocket. Thus, a surprise bill.

You may know this practice as balance billing, and it has been standard in the industry for some time. With the implementation of the new rules, balance billing is not allowed in most cases. A pretty clear explanation is laid out on the Investopedia website:

"As of Jan. 1, 2022, it is now illegal for providers to bill patients for more than the in-network cost-sharing price if the patient did not choose or know that the service would come from an out-of-network provider."

There are some exceptions, including land ambulance services. But by and large, the days of balance billing are pretty much over. The question is, does the No Surprises Act actually improve transparency in medical billing? Investopedia says it does.

3 Systemic Improvements

The No Surprises Act is clearly designed to protect consumers from a complex medical billing system that seems to always have them on the short end of the stick. The law brings three systemic improvements into play. First is full disclosure.

The law requires insurance carriers and healthcare providers to fully disclose all deductibles and out-of- pocket caps for both in- and out-of-network services. This essentially forces them to make sure that every patient has access to accurate and up to date information before receiving services.

Full disclosure is just the start. The law also requires insurance carriers and healthcare providers to offer cost estimates before patients elect to receive services. These must be good faith estimates based on published prices for both in- and out-of-network care.

Finally, and perhaps most importantly, healthcare providers and carriers are now required to maintain updated directory information. This is designed to prevent patients from mistakenly seeking care out-of-
network despite believing that they are visiting an in-network provider.

When Disputes Arise

No doubt the No Surprises Act will result in disputes between insurance carriers and healthcare providers. When they cannot agree on payment, they now need to seek out arbitration. The arbitrator will have to decide between the parties' respective final offers. Either way, the patient is off the hook. They will not have to pay more than the in-network cost for services rendered.

None of this affects medical billing codes, of course. But it may affect how billing codes are used to prepare invoices for insurance carrier submission. Do yourself a favor and study up on the new law. If it affects your work, you will need to pay attention.


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