New Federal Surprise Billing Law Impact on Medical Billing Reimbursement

New Federal Surprise Billing Law Impact on Medical Billing Reimbursement

Surprise bills are the most common concern of affordability for many In-Network and Out of Network (OON) patients. These bills are least expected and financially unmanageable as most of the times patients are unware that they had got service from an Out of Network provider until they get their Medical bills. Such unanticipated Medical Bills when patients are getting treated in hospitals or practice within the payers’ network cause an alarm to the patient’s family mentally and financially. To protect the Patients from such Surprise bills, On July 1, 2021, Federal Government has enacted and released the Interim Final Rule “No Surprise Act – Requirements Related to Surprise Billing Part 1” which will take effect from January 2022.

The “No Surprise Act” will protect physicians from balance billing for non-emergency medical services provided by OON providers during the patient visits in an In-network setup. As a rule, for Emergency Services, providers may only bill cost of sharing which is similar to the cost of covered services.

Emergency Care: 
Care provided during an Emergency Situation cannot be balanced billed even if it was from an OON provider.

Scheduled Care:
Doctors must provide a notice 72 hours prior to providing OON services and get the patients consent to bill the same.

Air Ambulance/Medical Transport Care:
Patients need to only pay the In-Network cost-sharing for any emergency medical transportation.
Apart from the above the new law also includes other provisions as listed below:

Insurance Company:
Effective Jan 2022 Insurance Companies should provide an advanced explanation of coverage details to their policy holders on request on how the services will be covered and charged. These detail on information should be provided in written communication within 3 business days.

Payers and Providers:
If a provider goes out of network or is no longer associated with the practice, the current law requires the patient and insurers to be notified and also provide transitional coverage up to the completion of treatment for 90 days at In-Network rates.

Updated Provider Directories:
The rule also mandates the Insurers and payer’s to keep the physician directory updated and also all inquiries related to providers should be attended to within 1 business day.  If the information provided is incorrect or not updated, patients should be charged on an In-network basis only

While the “No Surprise Act” protects the patients from unnecessary financial stress, it also has taken into consideration the providers and their reimbursement, keeping in mind the small practices and individual physicians. To know more about how this New Surprise Bill Act can affect medical practices and provides.

New Federal Surprise Billing Law Impact on Medical Billing Reimbursement
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