THE BUSINESS OF MEDICINE
What Every Physician Needs to Know About the ‘No Surprise Billing’ Act By Jayesh Shah, MD, MSc, UHM ABPM, CWSP, FAPWCA, FCCWS, FACHM FUHM, FACP
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et me start by sharing a story of a patient to help your understanding of surprise medical billing. The patient was a young diabetic male. He developed a wound on his foot, which became infected, and had to go to the emergency room. Then, he was admitted to an inpatient facility. He required various services from a variety of physicians during his hospitalization including surgical, hospitalist, specialist, anesthesia, pathology and radiology services. He ended up having his toe amputated during his hospitalization and was then discharged home. The patient was happy with the medical outcome, as he only lost his toe and was able to save his foot. But in the next 30 days, he started receiving large, unexpected medical bills. Upon checking with his insurance, he was told that some of the services he received were out of network, so he was responsible for the balance of those bills. Surprise medical billing generally happens when a patient receives out-of-network emergency care or receives care from an out-of-network physician or provider at an in-network facility. In these situations, the patient can get caught in between the provider and the insurance company. Some patients incurring surprise medical bills end up losing their savings, and some have faced unnecessary hardships trying to pay these surprise bills. These surprise medical bills also happen because many insurance companies have narrow networks. A narrow network means insurance companies do not contract with enough physicians, providers and facilities, which also causes a problem for the patient with access to more affordable care. Congress stepped in to protect patients by prohibiting balance billing in these scenarios (with certain exceptions) and removing the patient from these surprise medical billing disputes. When Congress 18
SAN ANTONIO MEDICINE • March 2022
passed the No Surprises Act, it sought to promote fairness in surprise medical billing payment disputes between insurance companies and providers. The Act also specified various factors that should be considered during the independent dispute resolution (IDR) process. The IDR process that was approved by Congress incentivized both insurance companies and providers to act in good faith and resolve disputes amongst themselves, keeping patients out of these discussions. The IDR process must be overseen by an independent and neutral arbiter who must consider several factors in deciding whether to select the provider’s or payer’s offer. Factors the arbiter examines include: • the “qualifying payment amount” for comparable items or services furnished in the same geographic area; • prior contracted rates during the previous four plan years; • market share of both parties involved; • provider’s training and experience; • patient’s acuity/complexity of furnishing the item or service; • if the provider is a facility, teaching status, case-mix and scope of services; • demonstration of good faith efforts by providers and facilities to enter into a network agreement. But on September 30, 2021, the U.S. Department of Health and Human Services (HHS) and other agencies departed from the language passed by Congress, which was designed to create a balanced IDR process. The interim final rule benefits commercial health insurance companies. According to the process under the rule, arbiters under the
