Today I would like to give some specific examples of what a “surprise bill” is.
Say a patient, John, schedules a knees replacement. He looks on the website that has the list of participating providers. He makes sure the surgeon is in his insurance plan. But what John does not know is that the anesthesiologist and the radiologist are not in his insurance plan.
Three weeks go by, and John gets an “explanation of benefits,” or EOB, from his insurance company. He is shocked when he sees that two costly items are marked “OON.” Even more shocking is that now he apparently owes almost $2,000 in “member liability.”
He calls his insurance company and is told that “OON” stands for “out of network.” He is confused, because the hospital was listed as a participating hospital and the surgeon was also listed as a participating physician. How could John know that the anesthesiologist involved in the surgery and the radiologist who read his X-rays were not? He never even met them.
The No Surprises Act protects people covered under group and individual health plans from receiving “surprise” medical bills when they receive most emergency services, non-emergency services from out-of-network providers at in-network facilities, and services from out-of-network air ambulance service providers.
Here is what it does not do. If John had no insurance, the No Surprises Act would only allow John to request a “good faith” estimate of the cost of the procedure. Not much comfort, even if he does ask.
I think it also highlights the out-of-control relationship hospitals and providers have with the charges for services. The cost of most services in healthcare is usually around only 30 percent of the amount charged. When hospitals and providers get the full charges for their services, it is a huge windfall to them. Let’s get down to the heart of the issue. In lending, we have “usury” laws. You can only charge a certain interest rate (unless you are Tony Soprano). Let’s implement similar laws in healthcare, limiting charges to a percentage of cost or some market value.
While it is common to have payer contracts include a substantial percentage discount off of your billed charge, the practice creates avoidable risk. Healthcare pricing
By now, most of you are surely familiar with the No Surprises Act (NSA), a federal law that protects patients from unexpected medical bills. The
Please log in to your account to comment on this article.
Join Beth Wolf, MD, CPC, CCDS, for an in-depth webcast on the FY2025 spinal fusion MS-DRG updates. Discover key changes in DRG classification, understand impacts on documentation and CMI, and learn strategies to ensure compliance.
Join Angela Comfort, DBA, MBA, RHIA, CDIP, CCS, CCS-P, as she presents effective strategies to strengthen collaboration between CDI, coding, and quality departments in acute care hospitals. Angela will also share guidance on implementing cross-departmental meetings, using shared KPIs, and engaging leadership to foster a culture of collaboration. Attendees will gain actionable tools to optimize documentation accuracy, elevate quality metrics, and drive a unified approach to healthcare goals, ultimately enhancing both patient outcomes and organizational performance.
Optimize your outpatient clinical documentation and gain comprehensive knowledge from foundational practices to advanced technologies, ensuring improved patient care and organizational and financial success. This webcast bundle provides a holistic approach to outpatient CDI, empowering you to implement best practices from the ground up and leverage advanced strategies for superior results. You will gain actionable insights to improve documentation quality, patient care, compliance, and financial outcomes.
Enhancing outpatient clinical documentation is crucial for maintaining accuracy, compliance, and proper reimbursement in today’s complex healthcare environment. This webcast, presented by industry expert Angela Comfort, DBA, RHIA, CDIP, CCS, CCS-P, will provide you with actionable strategies to tackle complex challenges in outpatient documentation. You’ll learn how to craft detailed clinical narratives, utilize advanced EHR features, and implement accurate risk adjustment and HCC coding. The session also covers essential regulatory updates to keep your documentation practices compliant. Join us to gain the tools you need to improve documentation quality, support better patient care, and ensure financial integrity.
Dr. Ronald Hirsch provides critical details on the new Medicare Appeal Process for Status Changes for patients whose status changes during their hospital stay. He also delves into other scenarios of hospital patients receiving custodial care or medically unnecessary services where patient notifications may be needed along with the processes necessary to ensure compliance with state and federal guidance.
Healthcare organizations face complex regulatory requirements under the No Surprises Act and Price Transparency rules. These policies mandate extensive fee disclosures across settings, and confusion is widespread—many hospitals remain unaware they must post every contracted rate. Non-compliance could lead to costly penalties, financial loss, and legal risks. Join David M. Glaser Esq. as he shows you how to navigate these regulations effectively.
Protect your facility from unwanted audits! Join Becky Jacobsen, BSN, RN, MBS, CCS-P, CPC, CPEDC, CBCS, CEMC, and take a deep dive into both the CMS and AMA guidelines for reporting post operative pain blocks. You’ll learn how to determine if the nerve block is separately codable with real life examples for better understanding. Becky will also cover how to evaluate whether documentation supports medical necessity, offer recommendations for stronger documentation practices, and provide guidance on educating providers about documentation requirements. She’ll include a discussion of appropriate modifier and diagnosis coding assignment so that you can be confident that your billing of post operative pain blocks is fully supported and compliant.
During this RACmonitor webcast Dr. Ronald Hirsch spotlights the areas of the OIG’s Work Plan and the findings of their most recent audits that impact utilization review, case management, and audit staff. He also provides his common-sense interpretation of the prevailing regulations related to those target issues. You’ll walk away better equipped with strategies to put in place immediately to reduce your risk of paybacks, increased scrutiny, and criminal penalties.
Copyright © 2024 RACmonitor. Powered by MedLearn Media.
Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →
