Surprise Medical Billing Becomes Popular Legislation Topic in 2020

Surprise Medical Billing Becomes Popular Legislation Topic in 2020

Working with an Extended Business Office Keeps You Up-to-Date on the Latest Laws

Surprises usually are intended to be fun, but not when it comes to medical bills. A surprise medical bill describes charges for healthcare incurred when an insured person receives care from an out-of-network provider, unbeknownst to them.

Surprise medical bills most frequently arise when the patient doesn’t have the ability to choose an emergency room, the treating physicians who work there, an ambulance provider, or even a surgeon or other operating room team member, such as anesthesiologists or radiologists. Bills from out-of-network providers can greatly exceed those from in-network providers, or require the patient to pay a larger deductible or coinsurance.

This year, surprise billing has become a hot topic in the House and Senate, as lawmakers push to pass legislation that would instate Federal surprise billing laws intended to protect patients from receiving unexpected medical bills. According to the Kaiser Family Foundation, surprise bills affect patients in 18 percent of emergency room visits. This average number varies greatly from state-to-state, reaching 38 percent in Texas, and dropping to 4 percent in Nebraska.

In a KFF Health Tracking Poll, 67 percent of those surveyed indicated they were very worried or somewhat worried about receiving unexpected medical bills; 53 percent said they were very worried or somewhat worried about being able to afford their health insurance deductible. The very same poll also found that eight in 10 Americans support the passage of Federal legislation to protect patients from surprise medical bills.

Although health care providers and facilities may dread what this new proposed legislation could enact, it seems the majority of Americans are likely to support the passage of these laws in an effort to better afford healthcare costs.

Proposed Federal Medical Billing Legislation

Of all the bills to pass through Congress, those that involve surprise medical billing appear to have bipartisan support. Currently, two are in consideration, after being proposed in February 2020.

The Consumer Protections Against Surprise Medical Bills Act of 2020, was put forth by Representative Richard Neal, D-Massachusetts, and Representative Kevin Brady, R-Texas. In this proposal, providers would be barred from balance-billing patients when they visit in-network facilities. The bill, if enacted, would require payers to provide a cost estimate with information on who will treat them, as well as the provider’s in-network status, ahead of any scheduled procedure. Unlike other similar proposals, this bill includes an outside arbiter who sets rates for out-of-network services.

The Ban Surprise Billing Act was brought forth by Representative Bobby Scott, D-Virginia; and Representative Virginia Foxx, R-North Carolina. This legislation limits patient cost-sharing to in-network rates only. The bill settles payment disputes between payers and providers based on the amount of the bill for care costing $750 or less, or $25,000 for air ambulance services. Bills that exceed these amounts will require using an independent dispute resolution.

At this time, neither bill has been passed by either the House nor the U.S. Senate, but they are receiving bipartisan and unicameral support.

States Take Action on Surprise Medical Bills

Individual states have enacted laws regarding surprise medical bills, although they tend to be more focused on people without employer coverage. These states include California, Connecticut, Florida, Illinois, Maryland, New Hampshire, New Jersey, New York, Oregon, Texas, New Mexico, Washington, and Colorado.

Each state’s laws are different, but they do have commonalities:

  • Hold patients harmless.
    • Insurers must cover out-of-network claims and apply in-network costs for any bill deemed as a surprise medical bill.
    • Providers may not balance-bill patients with state-regulated health insurance plans; the out-of-network provider must accept the in-network cost.
    • Patients must receive notice from the provider about their rights and protections under the law.
  • Resolve payments for surprise bills.
    • Provide resolution for the amount of surprise medical bills, either by adopting payment standards or establishing an independent resolution process, or both.

The Employee Retirement Income Security Act of 1974, or ERISA, limits states’ jurisdiction to protect privately-insured patients, like those with coverage from their employer-provided health plans. States are preempted from requiring employer plans to cover surprise bills from out-of-network providers, as well as from requiring plans to apply in-network costs to out-of-network medical bills. However, ERISA allows states to regulate group health insurance policies, although this may not protect many patients from surprise billing; 61 percent of covered workers’ policies are covered under self-insured group health plans beyond the reach of individual states’ regulation, according to the Kaiser Family Foundation.

Additionally, enacted legislation in some states is less comprehensive and only requires patients to be notified that they may encounter surprise medical bills; they are still allowed to receive them. Others only apply surprise billing laws to emergency care, or only to HMOs.

What Surprise Billing Legislation Means For Your Facility

Until these pieces of legislation are finalized and enacted, it is hard to predict precisely how your practice or facility will be affected. Staying abreast with the latest developments and discussing best practices with your network of peers can help you create a plan to navigate new medical billing laws.

It is likely that you have already made a point to educate patients entering your practice about surprise billing, or at least have provided general information about how medical billing and insurance coverage works. If not, the American Hospital Association has developed full-color brochures on the topic that you can download and print from their website,

Unfortunately, medical billing, payment processing, and patient education and communication can eat into your team’s time that could be better spent improving clinic operations or taking a proactive approach to preparing for the adoption of new laws. An extended business office, like Assistentcy, can take the day-to-day responsibilities of medical billing and early-out collections off your plate, regardless of where you’re located. Outsourced early-out billing saves you time and money.

To learn more about how Assistentcy can help you prepare for changes to medical billing laws and settle your self-pay patient accounts quickly, contact us online, or call 913-401-4752 or 888-455-7498.