The impact of patients receiving large, unexpected medical bills from hospitals and physicians has been covered extensively by the media.
Typically, this surprise billing situation occurs when a hospital or physician who is not “in network” provides care to a patient.
The Consolidated Appropriations Act COVID-19 relief bill signed into law on December 27, 2020, includes the “No Surprises Act” (the Act). Among other things, it enacts patient financial protections from surprise medical bills. The patient provisions in the Act are designed to protect patients from surprise bills resulting from unanticipated out-of-network care.
On July 1, 2021, the U.S. Department of Health and Human Services (HHS), along with the Departments of Labor and Treasury and the Office of Personnel Management, announced the first in a series of new regulations aimed at further restrictions of surprise billing.
These newest restrictions include:
- Banning surprise billing for emergency services; essentially qualifying all emergency departments as “in-network”
- Eliminating high out-of-network cost sharing for emergency and non-emergency services; co-insurance or deductibles cannot be higher than if the services were provided in-network
- Abolishing out-of-network charges for ancillary care at an in-network facility
- Eradicating other out-of-network charges without advance notice
To help ensure compliance, we recommend that radiology practice leaders:
- Determine whether your practice is covered under the Act. In some states, existing surprise billing laws supersede the new federal protections, provided that they are at least as comprehensive as the Act.
- Confirm with which payers your practice is “in-network.”
- Compare your “in-network” payers to the plans that are “in-network” for your practice’s facility partners.
- Establish a methodology to gather information and understand your practice’s plan participation status and how it impacts your billing and revenue cycle management (RCM) system and processes.
Patients Remain Responsible for Some Payments
Under the Act, patients can no longer be balance billed. This highlights the need for the hospital to capture complete insurance information for the patient up front, whenever possible, and to share it with you. Your practice must know the details of the patient’s insurance plan and coverage in order to submit a clean claim under the requirements of the Act. That said, patients are not fully released of financial responsibility under the Act. Even for out-of-network care, patients remain responsible for paying the amount that they would have been responsible for, had the practice been in-network. The Act allows the practice to bill that amount along with the claim reimbursement.
Consent Waivers and Radiology Practices
One of the unique aspects of the Act for radiology practices is regarding consent waivers. Under the Act, patients are covered for emergency services at out-of-network hospitals until they are stabilized. Then, the patient can choose to be transferred to an in-network facility or sign a consent waiver to continue to receive out-of-network services. In non-emergency circumstances, if a patient chooses to see an out-of-network provider in a facility where in-network providers are available, patients may sign a consent waiver allowing the facility and/or provider to balance bill the patient. However, unlike hospitals, radiology and other ancillary service providers are not allowed, under the Act, to use consent waivers. Therefore, radiology practices must follow the in-network payment policies of the Act.
Recommendations for Radiology Practices
To optimize reimbursement, radiology practices benefit from using insurance demographic verification and insurance discovery tools at the pre-billing stage to capture complete, accurate payer information for each patient.
The new billing process should look something like this:
- Run demographic verification and insurance discovery tools at the point of registration or when the patient’s demographic file enters into your billing system.
- If your practice treats a patient whose insurance plan considers you out-of-network, the claim gets submitted to the payer at the full fee schedule amount.
- When the practice receives reimbursement from the payer, it is critical that the claim is flagged to prevent automatically balance-billing the patient. Instead, billing staff first must evaluate whether the payer reimbursement is acceptable.
- If it is not, the practice has 30 days to come to an agreement with the payer or dispute the payment amount.
- The independent dispute resolution (IDR) process must be used in cases where an agreement on payment amount cannot be reached between the practice and the payer.
- The practice can bill the patient for co-payment, co-insurance, or deductible as reflected in the insurance verification process or via the explanation of benefits (EOB) from the patient’s insurance plan. Insurance verification tools, as well as accounts receivable (AR) optimization tools, are valuable in determining the patient’s propensity to pay and eligibility for charitable discounting. These tools will result in a higher portion of the patient responsibility being collected.
We recommend that radiology practices develop a plan for managing out-of-network claims compliantly under the Act. Leveraging AR optimization tools early in the RCM process maximizes reimbursement for eligible services.
This article is a collaborative effort with ZOLL Data Systems.