(3 min read) Large, unexpected medical bills are increasingly at the forefront of patients' minds. Surprise billing situations occur when a patient receives care from an out-of-network physician or hospital, and insurance doesn't cover the cost. Decreased payments result when a patient suddenly finds themself responsible for a significant portion of the bill.

The Consolidated Appropriations Act COVID-19 relief bill was signed into law on December 27, 2020, and it includes the “no Surprises Act” (the Act). This allows protections from surprise medical bills for the patient that are a result of unanticipated out-of-network care. Then on July 1, 2021, the U.S. Department of Health and Human Services (HHS), along with the Departments of Labor and Treasury and the Office of Personnel Management, announced new regulations to further restrict surprise billing for patients.

These newest restrictions include:

• Banning surprise billing for emergency services (essentially qualifying all emergency departments as “in-network”)
• Eliminating high, out-of-network cost sharing for emergency and non-emergency services (co-insurance or deductibles cannot be higher than if the services were provided in-network)
• Abolishing out-of-network charges for ancillary care at an in-network facility
• Eradicating other out-of-network charges without advance notice

To help ensure compliance, our top recommendations for radiology practice leaders are:

• Determine whether your practice is covered under the Act. In some states, existing surprise billing laws supersede the new federal protections, provided that they are at least as comprehensive as the Act.
• Confirm with which payers your practice is “in-network.”
• Compare your “in-network” payers to the plans that are “in-network” for your practice’s facility partners.
  
  
  

Patients Remain Responsible for Some Payments

Under the Act, patients can no longer be balance billed. This highlights the need for the hospital to capture complete insurance information for the patient up front, whenever possible, and to share it with you. Your practice must know the details of the patient’s insurance plan and coverage in order to submit a clean claim under the requirements of the Act. However, patients are not fully released of financial responsibility under the Act.

Consent Waivers and Radiology Practices  

One of the unique aspects of the Act for radiology practices is regarding consent waivers. Under the Act, patients are covered for emergency services at out-of-network hospitals until they are stabilized. Then, the patient can choose to be transferred to an in-network facility or sign a consent waiver to continue to receive out-of-network services. However, under the Act, consent waivers are not allowed in radiology and other ancillary services.

Recommendations for Radiology Practices

We have several recommendations for radiology practices to optimize reimbursements. Using insurance demographic verification and insurance discover tools at the pre-billing stage to capture complete and accurate payer information on a per-patient basis.

We’ve outlined a recommended billing process for radiology practices that will comply with the new rules outlined in the Act. This process includes what to do if a patient’s insurance is considered out-of-network, how and when to utilize an independent dispute resolution (IDR), and the importance of accounts receivable (AR) optimization tools. AR tools will be an incredible resource in determining the patient’s ability to pay.

To learn more about how the No Surprises Act impacts radiology practices, read the full article in Becker’s Hospital Review.