Mar 22, 2023

All About Surprise Medical Billing

  • By Eva Johnson,
All About Surprise Medical Billing

Surprise Medical Billing is one of the major causes of medical debt. This surprise billing happens when patients receive the treatment from out-of-network healthcare providers, often unknowingly and involuntarily and their insurance plans cover only a segment of the cost of care or in some cases none.

This is also known as “balance billing” because in this case, the insurance providers are requesting the patients to pay for the difference between the insurer’s payment and what the healthcare has charged the patients which is usually much higher than the in-network price for the healthcare services.

Surprise medical billing has affected one in every five Americans, and this sums up to the amount of $40 billion each year.

This has resulted in patients and their families watching their credit being destroyed, even moving towards the bankruptcy, despite having the health insurance.

Thirty-two states, including Illinois, have already passed laws in motion for barring the surprise medical billing to some extent of varying degrees. Now, after the arrival of the sudden arrival of the pandemic several bipartisan federal bills were also drafted. Finally, this issue was re-addressed by congress in the pandemic relief package passed at the end of the year – 2020. It was renamed as “No Surprises Act”. This law was enacted to protect the patients by removing them from the disputes on billing between the insurers and providers.

This law stated that insurance plans have to provide coverage for receiving healthcare services out of network under two circumstances which are:

  1. Firstly, emergency care, in which if the patient comes to an out of network healthcare facility to get a medical emergency then all the care received until the patient is discharged from the facility or stabilized enough to be transferred will be covered according to the in-network benefit level.
  2. Secondly, in case the out of network healthcare provider is providing the facility in the network healthcare system, then you will not be liable according to the out of network payment and that will be insured and paid according to the share for in-network services and facilities.

The law has prohibited the providers from sending the bills to patients in the situations as explained above.

The “No Surprises Act” will be in effect in January 2022, as the Secretary of Health and Human Services needs some time to come up with the rules to enforce this law in the healthcare system. Providers and insurers have to implement data and paperwork changes according to the law.

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