The US government published an interim final rule (IFC) last year regarding the surprise billing act. This rule outlines the No Surprises Act requirements for group health plans and carriers, payers, medical service providers, and other ancillary services. These regulations will be effective for providers starting January 1, 2022, and for others beginning or following January 1, 2022, depending on the contract date.
Medical Billing Services
What is the Surprise Billing Act?
The surprise billing act was created to stop surprise billing. Out-of-network billing is also called “surprise medical bills.” It occurs when a patient receives a bill that exceeds the amount of the out-of-network provider’s fee. This bill accounts for the variance in the insurance amount after deductibles and copays. These bills occur because the provider and insurer don’t have a contract. The provider charges the patient for any amount that is not covered by the insurance plan.
The “surprise billing” act prohibits out-of-network providers from billing patients for more than a specified amount. A penalty can be imposed for each case that is found to be in violation. However, the act provides some exceptions to these protections. This exception applies if the patient is fully aware of the consequences and uses an out-of-network provider for non-emergency services. The act requires that carriers make the first payment to the provider. If a bill is submitted with denial, the carrier must make the first payment to the provider within 30 days.
Five Tips to Improve Healthcare Revenue Cycle Management
To maintain strong financial health, you should continuously review your revenue cycle process.
To ensure that there are no gaps in your revenue cycle management process, you should examine it. These gaps may appear at any time and can go unnoticed. It is only when your team is having trouble creating clean claims, struggling to keep denied claims under control, or is unable to stop bad debts from growing that you realize there is an issue. All stages of your revenue cycle should be reviewed. The pre-service, or eligibility verification, stage is the most important. because mistakes made at the registration stage can lead to 40% of healthcare denials.
Among the errors made at this stage are:
- Incapacity to collect accurate and complete insurance and demographic information
- Incomplete or incorrect insurance verification
- Inability to understand the requirements of a health plan
- Inability to pass a mandatory screening
- Inability to obtain authorization prior to use
Patients should be given accurate out-of-pocket estimates.
Adopting Medcare Medical Billing Services (MSO) can help to solve many of the problems that arise at this stage. Providers must first review the information collection process. The best way to automate the process is to do it electronically. Training and educating front-end employees is another important requirement. It is also important to establish a tech-driven process for identifying insurance plans and verifying eligibility. Another important factor is teaching staff how to interact respectfully with patients. It should be friendly, clear, and easy to understand.
Provide an Advanced Explanation of Benefits (EOB).
EOBs are very important under the Surprise Billing Act. To comply with this act, providers must provide a clear and timely EOB notification to patients. The EOB must include information about the provider’s participating status and the contracted rate. The EOB should clearly indicate how the patient can access information about participating doctors at the facility if the facility is not in-network.
EOBs should also be focused on the provider’s good faith estimate. Based on the estimate, the estimate must clearly indicate the amount that the plan will be responsible for paying. Also, the estimate must clearly indicate the patient’s out-of-pocket cost and deductible. Providers should also state that coverage is subject to medical management requirements and that the estimated amount is an estimate and could change.
Establish A Process To Keep Provider Directories Up To Date.
While this is more of a payer’s responsibility, providers can play an important part in keeping directories up-to-date. The new law requires that both payers and providers ensure timely delivery of directory information to plans by 2022. Any provider not in compliance with network status must be removed. In-network rates will not be accurately estimated if provider directories contain provider names. The plan cannot impose a cost-sharing amount that is higher than the in-network rate. Providers must ensure that their name appears in the directory. If it does not, they must dial the payer to get it corrected.
Review the Contracts with Payers and Taylor Out-OfNetwork Mitigation Strategies
Arbitrations are one of the most likely outcomes of surprise billing. As providers have to spend money to settle disputes, this will result in new administrative costs. It will not only increase their costs but also make them more resource- and time-intensive. Providers will have to accept lower reimbursements, which could impact their long-term sustainability.
Providers should review both out-of-network and in-network contracts that they have with payers to reduce the impact. Providers should make every effort to reach in-network participation agreements. Arbitrations will be less expensive if this is done. In-network rates will be lower for payers.
Communication with patients and collaboration between providers and payers can make a big difference in serving one another’s interests. Patients will be more willing to pay more for out-of-network services if they are aware of the costs. Price transparency will also help providers address the No Surprises Act’s challenges in 2022. Transparent pricing information can be used by all stakeholders to resolve issues related to rates during final arbitration and open negotiations.
Prioritize Operational Efficiency and Cost Savings
Balance billing will be a thing of the past by 2022. Providers who practice balance billing should be prepared for a cash loss. Providers must find cost-saving opportunities by streamlining their operations to mitigate this loss. A good way to reduce costs is to perform performance reviews that use lean processes. This will eliminate wasteful spending, increase throughput, and reduce overall costs.
Who are we and what makes us experts?
This article was brought to you by Medcare Medical Billing Services (MSO), a specialist provider of revenue cycle management healthcare for providers in the US. We provide a wide range of revenue management services for healthcare. These services include medical billing, medical coding, and claim denial management. Professionals with extensive experience in revenue cycle management as well as advanced service systems drive our well-developed process. We have worked with many US-based clinics and hospitals over the years to improve their revenue cycle processes. We can help you find the best revenue cycle management services for medical professionals.