Surprise billing and price transparency: 5 key insights on rule compliance 

Healthcare organizations are ramping up price transparency efforts this year to achieve compliance with new rules from CMS and help patients better understand the cost of their healthcare services.

During Becker's Health IT + Revenue Cycle Management Virtual Forum Feb. 9, Howard Bright, vice president of patient engagement at RevSpring, discussed new rules and tips for providers to craft an effective patient financial engagement strategy.

Five key takeaways from the presentation:

1. The new surprise billing regulations apply to both health plans and providers and are meant to protect patients from situations where they aren't expecting to be billed out-of-network prices.

"The No Surprises Act is really focused on this concept of patients getting out-of-network bills when they are at an in-network facility," Mr. Bright said. "It's a consumer protection bill, designed to protect patients from billing situations where they aren't expecting to be billed out-of-network prices."

2. For the health plan side from the surprise-billing standpoint, health plans have to hold all their enrollees harmless for any amounts that go above in-network amounts charged by out-of-network emergency service providers.

"This means that if you are getting emergency services at an out-of-network emergency service provider, the plan cannot charge you, force you to pay or expect you to pay anything beyond what is the typical in-network pricing," Mr. Bright said.

3. On the provider side, the No Surprises Act prevents providers from balance billing, so out-of-network facilities can't balance bill for any services above what the in-network price would be.

"If you're an out-of-network provider delivering emergency services and a patient comes in, you can only bill them at their in-network rates and you can't balance bill them for the difference," Mr. Bright said.

4. As of Jan. 1, all hospitals must comply with the new price transparency regulations, which requires hospitals to publish a list on their website of all their standard charges for items and services it provides.

"This only applies to hospitals; so physicians, groups, specialists, etc., do not have to publish their prices. The only time that they would have to is if they are employees of a hospital system," Mr. Bright said.

5. Interactive pricing tools are the best opportunity to help patients navigate pricing under the new surprise billing and price transparency legislation.

"Instead of just giving your patients a big PDF file to download and search through it to find their insurance and procedure they want, you can give them a tool where they can just type in what they want," Mr. Bright said. "Then you open up all these opportunities to be able to guide them, and you get a great first impression for your organization and you can brand it how you want."

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