No Surprise. It’s Not Surprising

Sticker shock no more.

Today I will be giving you my point of view on the No Surprises Act – a topic of great interest in healthcare circles.  It was clear that the Centers for Medicare & Medicaid Services (CMS) heard the grievances regarding the skyrocketing costs of healthcare and bills from providers that do not make sense (not to mention being exorbitant), because now, as consumers, you have every right to not be surprised anymore.

While providers had the luxury of 14 months to prepare for the price transparency rule, effective Jan. 1, 2021, most still thought it would be delayed, much like ICD-10; but not a chance! It is now in effect, with more than an estimated 50 percent of providers not in compliance. 

With the No Surprises Act, providers must be ready to be completely transparent with their costs for procedures performed when you, as a consumer, receive care in a non-emergent or emergent setting. It is important to note that this rule only applies to those who participate in group health plans, group or individual health insurance coverage, Federal Employee Health Benefits (FEHB) plans, and the uninsured. So, for all of you who have coverage through Medicare, Medicaid, Indian Health Service, Veterans Health Administration, or TRICARE, the No Surprises Act does not apply currently, but stay tuned, as the new rule may have a trickle-down effect. These later programs have other protections against high medical bills, such as prospective payment and established fee schedules.

The Act was enacted to address the issue of surprise medical bills, and limits the amount that an insured patient has to pay for services when the patient/consumer does not have control in emergency situations and cannot select the emergency room, ambulatory services, or physicians of their choice. Additionally, it takes effect when a patient/consumer schedules a procedure, such as surgery, from an in-network provider and the provider chooses anesthesia or pathology services, as examples, from an out-of-network provider. Unfortunately, this happens more often than not. Thus, when out-of-network providers provide care, the consumer is shocked when hit with a high cost of services in such settings – often leaving providers and patients negotiating coverage of these bills.

The No Surprises Act places the burden of negotiating surprise medical bills between the provider and the health plan through dispute resolution if it cannot be resolved in 30 days. The Act also requires plans to create policies and procedures to address the transparency rule.

As it relates to my point of view, I have the luxury of providing two of them. Today, I will be able to provide a consumer and provider perspective. 

Scenario I: No Surprises Act
As a consumer, I have had the unfortunate privilege to experience surprise medical bills firsthand. I wish the No Surprises Act was around a few years ago, after a family member’s ambulance ride to the emergency room turned into significant dollars out of pocket! Consumers, be careful, as with COVID there has been a shortage of ambulance services, and while many have merged with others, there are just as many private companies that more than likely may not be on the preferred provider list of your health plan. 

Providers, while you do not have control over COVID and its aftermath, please do not assume that the average consumer knows about the No Surprises Act! Be an advocate for the patient and do the negotiating for them, instead of expecting them to pay for out of network services; you know that most will end up paying the bill!

Scenario II: Price Transparency
My next experience was in preparing a friend for inpatient surgery. Because my friend is on a fixed income and I was aware of the price transparency rule, I recommended that my friend call their provider to understand what their out-of-pocket responsibility would be for the surgery. My friend was asked by the provider for the CPT codes associated with surgery, as well as “if they could spell out the procedure, because they are not medical.” Seriously? Now, if I hadn’t been there to coach my friend, what layperson is going to know what a CPT code is, or how to spell a complicated procedure, if the consumer’s background is not medical?    

Providers, break down the transparency rule. In this scenario, the provider was prepared, but they did not have the consumer in mind when they put a non-medical person in a position where they needed a spelling lesson! While a non-medical person is cost-effective, give them the tools they need to be successful. Providers should offer robust search tools that allow a “non-medical” person the ability to perform a search, with “auto-suggestion” that can pull not only the CPT codes, but the ICD-10 codes as well, based on the procedure the consumer provides. 

While the No Surprises Act is long overdue, what’s next? What happens once facilities start analyzing their losses or analyzing the procedures ordered by physicians that were not reimbursed? Will facilities ask physicians to back off the orders, meaning no more CYA procedures being ordered? Didn’t think about that? Ultimately, will overall care be compromised for all covered entities? Will the analytics alter how facilities do business? 

For those of us like me, who interpreted and educated prospective payment systems for multiple facility types nationwide, we saw how for inpatient, outpatient, inpatient rehab, and home health care, to name a few, the analytics highlighted how to improve your bottom line (yet ultimately, in some cases, compromised care). For any of you who have aging parents or loved ones, be aware! Now, you are probably thinking back to the notion that the No Surprises Act does not apply to the elderly, as those with Medicare, Medicaid, Indian Health Services, Veterans Health Administration and or TRICARE are already protected; it’s true,  they are. But think for a minute: when physicians order procedures, they never ask what insurance you have before writing orders. Unfortunately, many of us foresee the trickling-down effect to our seniors, as they will continue to be the victims. 

So, consumers out there, please pay close attention to the care you are receiving, and know your rights! Take the time to understand how this rule benefits you and your loved ones. For the providers out there, please pay close attention to the care you are providing, and know the rules and regulations that apply to your facility! Take the time to understand and comply with the No Surprises Act; if you are not prepared, there are risks of paybacks from reprocessing denied claims, penalties, and possibly, punitive damages.

Now, for all of you who were hoping to get the nitty-gritty details of price transparency and the No Surprises Act, stay tuned for subsequent articles on these topics.