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A new Year, an early Gift

By Martine G.Brousse

Patient Advocate, AdvimedPro

January 11, 2022



Amid the long-lasting Covid menace, inflation fears, financial uncertainty and the distressing shortage of my favorite Costco shampoo, 2022 looks a lot like ... before.

Except that the best gift to patients since the implementation of Obamacare in 2010 has been let loose on the healthcare industry on January 1st, with too little notice and not enough fanfare. I mean the new federal law: the No Surprise Act. (Not to be mistaken for the Agency)


The Basics :

  1. In Network vs. Out Of Network: "In" means the facility or medical provider has signed a special agreement with your insurance and will accept a lower payment, saving you money. "Out"means there is no such contract, and that the whole amount billed by the facility or the medical provider can be billed to you.

  2. When an Out Of Network provider bills you for the difference between what their charge is and what your insurance may have paid, it is "balance-billing"

  3. Facility vs Professional charges:

  • Facility: a hospital, surgicenter, imaging center, urgent care center, infusion center etc. The charges include the use of that "building", including medications, equipment, operating rooms, beds, medications, lab, supplies, etc. It also includes the time of salaried staff.

  • Professional: that is an individual physician, therapist, nurse who is not employed by the facility and is independently providing services there but billing separately.

  • Many services, such as imaging, ER or surgery will result in 2 bills: one for the use of the equipment ("facility") and one for the time and expertise of a physician ("Professional").

4. Commercial vs. not Commercial

  • Commercial plans are those from an employer or bought by individuals on the open market or Obamacare marketplace. They usually cover members under 65

  • Medicare, Medicaid, Tricare are government-issued plans, which follow they own coverage and guidelines. They are usually not subject to the same laws, State and federal that commercial plans must.


What is NSA?

  • the most sweeping change in the healthcare industry in a decade

  • it covers single commercials plan in the US including ERISA (self-funded) policies and grandfather coverages (the few dinosaur plans still in existence)

  • Medicare, Medicaid and Tricare plans have their own regulations and are not affected

  • It implements widespread new protections against the balance-billing of patients by non contracted ("Out of Network") providers

  • It protects you and me from receiving "surprise" bills from providers we may not have hired or consulted, and who were billing us the difference between their billed charges and what an insurance may have reimbursed.

What it says:

  1. Emergency services

  • As of 1/1/22, most services rendered as the result of an emergency (meaning life or limb at risk, labor, or other condition(s) which a patient has reason to believe is acutely jeopardizing his/her health) must be paid by your insurance at the higher "In Network" rate> This equals what it would have paid if that provider had a contract.

  • Emergency services may be rendered at a hospital, clinic, urgent care center or any other facility licensed to provide emergency care.

  • Services may be rendered by any and all medical professionals rendering services to you in those settings (surgeons, ER Drs, anesthesiologists, specialists, pathologists, radiologists etc)

  • Providers must accept that In Network allowance, and must adjust their balance accordingly.

  • Providers may no longer balance-bill you for the difference between the amount they billed and what the insurance allowed and/or paid.

  • Insurance companies must process such emergency claims at the higher In Network rate regardless of the contractual status of the facility or physician.

  • Insurance companies must provide clear Explanations Of Benefits showing medical providers and patients what the In Network allowance is and how much (if any) liability may be billed to the patient.

  • Emergency services also include air ambulances, screening, medical equipment etc.


2. Post emergency care

  • Services necessary in order to "stabilize" a patient and eventually transfer him to an In Network facility or discharge him home are now covered under this Act.

  • If you need immediate surgery or to be admitted as inpatient in order to save your life or allow your condition to improve - enough for a discharge or transfer - those services must be paid by your insurance at the higher In Network rate.

  • Insurance companies must process such claims at the higher In Network rate regardless of the contractual status of the facility or physician.

  • The facility and medical professionals who rendered the post emergency stabilization services must again accept In Network rates and are no longer allowed to balance-bill you.


3. Non emergency services at In Network facility

  • Professional services rendered at an In Network facility by non-contracted ("Out Of Network") providers are covered under this Act

  • The Act follows several States' existing laws (such as CA's AB72) which force insurance companies to cover those services at the higher In Network rates.

  • Insurance companies must process such claims at the higher In Network rate regardless of the contractual status of the physician.

  • Providers must accept that In Network allowance, must adjust their balance accordingly and may not bill any patient for the difference between their billed amount and the insurance allowance.

  • Non emergency services cover a range of places of service (hospitals, surgicenters and outpatient departments).

  • Other services rendered within that facility: lab, imaging, medical devices, pre and post surgical visits and even teledoc visits.


What is good:

  • The burden of dealing with post-service surprise bills, and fighting insurance companies or aggressive billing staff is quite over for most commercial patients.

  • The range of services affected by this new Act is broad and will eliminate millions of bills to patients who did not have a say in who rendered services to them, or even which hospital the ambulance drove them to.

  • Patients may not be asked or forced to pay a physician up front in order to receive emergency services or non emergency services at an In Network facility. The provider now must wait for the insurance to process the charge, discount their bill as per the Explanation of Benefit and then can only bill you for the amount, if any, determined by the policy to be your responsibility.

  • The burden of billing your insurance, and fighting it if a payment is incorrect no longer falls on patients. Billing services now have the duty of making a pre-service agreement with the insurance, or appealing after the facts if they feel their reimbursement is incorrect or too low.

  • Insurance companies have 30 days to process a claim including engaging in a one-time negotiation with a medical provider.

  • Waivers (see below) are not allowed for a range of services including Emergency-related, lab, radiology, assistant surgeons, hospitalists, and more.


What is not-so-good:

  • Certain medical providers have a "way out" by asking patients to sign a waiver, and may therefore bill them for their whole charge regardless of how the insurance processes their charge

  • Although medical providers are not allowed to coerce or pressure any patient to sign this waiver, they retain the right to deny services to those who do not sign it. This may lead to patients being forced to sign the waiver and pay full price in order to receive the services, especially if there is no better or available alternative.

  • This new system is so extensive in scope that snafus, delays, errors are to be expected for at least several months. Patients should make sure their Explanations Of Benefits indicate "In Network" rate for all appropriate charges.

  • Billing office systems may take a while to be set up to accept lower insurance payments and may send statements to patients too early. I recommend that you contact the office, and inform them they may be in violation of the NSA act, and demand to place the account on hold until resolution through the insurance.

  • Enforcement is spread over several federal agencies depending on the type of policy, which may create confusion in reporting violations or filing grievances against insurance companies.

  • Grievances against medical providers who might be in violation of the Act fall under the States' responsibility, which may not have a working reporting system in place for several months.

  • States may have the right to implements their own laws if broader in scope, or to limit that of the NSA Act.


In conclusion:

  • This Act is a huge step toward curbing patient balance-billing, the high rate of bankruptcies due to medical debt, and the trend by medical providers to operate without any contract with insurances and expect 100% of their fee to be paid by patients.

  • It will take time to implement this new process at multiple levels, and patients should expect unwarranted bills, insurance processing errors and frustration for several months... at least.

  • Patients should remain vigilant about any liability billed to them, and should contact the billing office or the insurance to get clarification.

  • Patience is a virtue. It will be tested this year but for millions of medical bills this year, the light at the end of the tunnel has been reached.



@ Martine G. Brousse 2022

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