While clear, upfront communication through an integrated billing and payment platform helps educate patients of their financial obligation, even hospitals don’t always see a surprise medical bill coming. Surprise billing has been labeled a “market failure” by collection experts who testified to Congress in 2019. It’s a complicated issue rooted in the long-standing system in which hospitals and doctors negotiate contracts with insurance companies.

The matter recently made it to Congress, leading to the No Surprises Act, which was signed into law. Under the No Surprises Act, patients will be protected from surprise medical bills starting January 1, 2022.

Surprise Medical Bills are a Major Source of Patient Stress

According to Health Affairs:

“This new bipartisan, bicameral legislation is the culmination of two years of hearings, mark-ups, campaign ads, and negotiation. Congress has gotten close before, but never this close. The No Surprises Act includes several changes from prior compromise bills. These changes largely center on the mechanism to determine how much out-of-network providers will be paid by insurers. Unlike many prior bills, the No Surprises Act does not establish a benchmark payment standard for insurers to pay out-of-network providers. Instead, insurers and providers will try to resolve payment disputes on their own. If that fails, these stakeholders can turn to arbitration”.

Surprise medical bills keep many Americans awake at night. A recent Harris Poll conducted on behalf of The American Heart Association found that nearly half of Americans concerned about a surprise medical bill don’t seek care because of that stress. Also, 44% report that they would not be able to pay a surprise medical bill of more than $1,000.

Hospitals and physicians get paid at rates negotiated under contract. Surprise bills arise when, for various reasons, hospitals and/or physicians do not accept the contracted rate and opt for out-of-network status. This often includes emergency room doctors who often contract as a private group to cover a hospital’s emergency department.

ER Patients are Especially Vulnerable

One recent study found that an out-of-network doctor treated one in five ER patients. Unlike scheduled care, where a patient can request an estimate for their out-of-pocket costs, ER patients require medical care unexpectedly due to an accident or serious illness (such as a heart attack). These patients have little or no control over who provides their care. In essence, the patient is billed out-of-network for whatever amount the provider decides. There are numerous examples of patients charged at rates well above Medicare rates, the medical field’s standard reimbursement baseline.

How Patientco Supports Compliance with the No Surprises Act

In March 2020, Patientco introduced new COVID-19-related system checks. These system checks identify and suspend bills, so they aren’t sent to patients who received treatment for COVID-19. Patientco has expanded this technology to help health systems comply with the No Surprises Act. With this technology, health systems can protect their patients from surprise medical bills.

“Patientco’s SmartCommunication platform will intelligently identify patient bills that do not pass specified regulatory, compliance and health system policy checks,” says Sean Joyce, Patientco’s Chief Technology Officer.

The goal is to reduce the likelihood of inadvertently sending surprise medical bills to out-of-network patients that do not meet the new rules. Applying these capabilities to support compliance with the No Surprises Act is yet another way Patientco’s technology is built to be “future proof.”

Meet the Author: John W. Mitchell’s job titles have ranged from sailor in the U.S. Navy (broadcast-journalist aboard an aircraft carrier) to COO and CEO for several hospitals. In 2009, HealthLeaders Media named John and his senior executive team the Top Leadership Team in Healthcare for turning around a 90-bed, regional Washington hospital. In 2012, he started his own business, SnowPack Public Relations. John is widely published as a freelance reporter and writer in the hospital, healthcare, and medical sectors. More recently, his projects include writing content on behalf of Patientco. John is also the author of the novel Medical Necessity (four stars on Amazon), and he is a commercially successful landscape and wildlife photographer.