Thursday, January 25, 2024

3 ways prevent surprise medical bills

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3 ways providers can help prevent surprise medical bills

Surprise medical bills may be the main problem for anyone, but they are especially difficult for small company owners and their employees. After going to the doctor for necessary treatment or service, no one likes to be surprised with unexpectedly high bills. The financial pressure they bring may lead employees to be less engaged and productive at work.

For many Americans, healthcare is already extremely expensive. A big, unexpected medical bill might put you in debt or force you to ignore required healthcare due to financial worries. Nowadays, a variety of state regulatory safeguards can avoid such unexpected medical expenses. However, a new federal law aims to make healthcare expenses more predictable and less demanding. The No Surprises Act, which takes effect on January 1, 2022, would provide comprehensive, consistent protections against unexpected medical bills.


As an employer who sponsors a team health plan, you may be able to assist your employees in avoiding or minimizing unexpected out-of-network billing expenses. So today, we are going to discuss how to prevent surprise medical billing. Please continue reading to discover more about surprise medical billing and how businesses and employees may avoid them. So here we go!

What are surprise medical bills?

Many consumers may be unfamiliar with the specifics of staying in-network vs. seeking out-of-network treatment. Unexpected out-of-network costs that a patient gets accidentally at treatment time might result in surprise medical bills. Because patients are unaware of the charges, they cannot avoid these out-of-network billing scenarios and wind up paying more in medical bills. 

According to the Kaiser Family Foundation, 18 percent of emergency visits and 16 percent of inpatient stays at in-network hospitals resulted in at least one out-of-network cost. If a provider does not have an agreement with your health insurance policy, they are considered out-of-network. This indicates that the practitioner and your insurance have not agreed on a reimbursement rate for health care services, and you may be liable for the gap.

Certain medical specialties are more likely than others to be out-of-network. Healthcare Cost Institute examined over 600,000 in-network procedures and their related out-of-network charges in 2016. According to the study, some specialties, like anesthesiology and emergency care, had the most significant rate of out-of-network claims.



How can surprise medical bills occur?

Surprise medical bills are common if you utilize out-of-network practitioners by accident or in an emergency. If you have a medical emergency, you will usually be treated at the nearest hospital or immediate care facility, independently of whether they are part of your insurance policy’s network. Usually, you do not have the option of selecting your service providers.

Even in non-emergency situations, you may not always have complete information or control over which services take your insurance. For example, if you go to an in-network hospital for care, you could still obtain tests, scans, laboratory testing, or other services from practitioners who work with the hospital but are not in your network.

When you are using insurance that pays for health treatment, your insurance company pays a percentage of the cost, and you pay a specific rate out of pocket, depending on the conditions of your health plan. Whatever you pay is frequently a copay, deductible, or co-insurance payment. However, when you utilize an out-of-network service, the cost-sharing amount is generally substantially higher. As a result, when the bill arrives, you’re faced with an unexpectedly high out-of-pocket expense.

The second method unexpected costs might occur is through balance billing. Balance billing occurs when an out-of-network providers bills you the gap between what your insurance agrees to pay and the entire amount of your invoice. Because the provider does not have an agreement with your insurance carrier, they are permitted to do so.

Ways to prevent surprise medical bills

Hospitals and health systems should implement new strategies and procedures to aggressively minimize unexpected expenses and maintain compliance with current federal standards. This should involve increasing the number of financial counselors on staff and investing in the appropriate technologies to avoid unexpected medical expenses from reaching patients.

The three areas of revenue cycle operations listed below are critical in creating a great medical billing experience. In other words, ways to prevent surprise medical bills.

1. Redesign your financial clearing procedure.

Financial clearance is a procedure that analyzes a patient’s capacity and likelihood to pay, assures they are informed and that they are financially prepared to afford the cost of their treatment.

The simplest way to do this is to:

  • Be as open as possible with the patient about what they should estimate their cost, particularly for primary operations or treatments.
  • Offer financial advice

On the other hand, most revenue cycle teams frequently try to manage duties such as handling scheduling. At the same time, they are attempting to get patients cleared by insurance firms for treatments to be given and have limited time or capacity to be aggressive with patients on their invoices.

By embracing automation, health system administrators may assist elevate employees by transferring their time and emphasis to more complex tasks or retrain current staff to offer financial counseling, which improves operations and the patients’ overall economic environment.

2. Verify your criteria for significant operations as early as feasible.

Front-end revenue cycle staff are frequently only able to work 2–3 days out to acquire prior permission from insurers for procedures such as surgery, resulting in a rush and difficulties such as unexpected, out-of-network payments for patients. The correct automation systems may assist revenue cycle employees in determining accurate estimations, forecasting rejections, and choosing the financial assets a patient may require weeks before the planned procedure.

3. Initial eligibility should be regular practice in the sector.

To minimize difficulties for both patients and providers, it is best to validate a patient’s insurance before stepping foot in the doctor’s office or site of service. Out-of-network providers, for example, can be identified by automation and brought to the patient’s knowledge ahead of time.

The intricacy of healthcare reimbursements increases hidden expenses, affecting what each individual spends and decreasing individuals’ trust in their medical system. According to the Centers for Medicare and Medicaid Services, the United States spent nearly $3.8 trillion on healthcare in 2019, or approximately $11,582 each person.

One of the most challenging problems for industry executives is striking a balance between controlling financial margins and providing excellent service.

To prevent patients from inaccurate, surprise medical bills on a large scale, methods that address the core causes of the problem are required. When technology is used to make revenue cycle processes more effective and precise, it may guarantee that patients receive the treatment they require without being surprised with unexpected medical expenditures.

Other preventing ways,

4. Advise individuals that they might try to deal with unexpected medical expenditures.

Individuals can try to resolve an out-of-network billing condition by directly engaging the healthcare professional and their healthcare insurance carrier, depending on the factors. Out-of-network physicians and insurance firms can negotiate a lower cost for the medical bill or, in some cases, eliminate the fee for the balance remaining after the insurance claim.

Workers should contact ER physicians for paperwork indicating that they could not select how they were transferred and that their care was medically necessary if the unexpected charge is the consequence of an emergency circumstance or out-of-network medical assistance.

5. Learn about facility costs

Facility fees, another source of surprise medical bills, are not the consequence of out-of-network billing costs. Alternatively, some hospitals charge facility fees for the use of their medical instruments and facilities, in addition to other expenditures made during the consultation. Hospital-owned clinics may pay facility fees to offset facility upkeep costs.

Are there any measures for surprise medical bills?

Several federal and state protections prevent surprise medical billing, but many gaps might still find you with a bill that you did not expect.

The Affordable Care Act provides current government protections against surprise medical bills (ACA). The ACA requires most private medical plans to apply in-network cost-sharing levels for urgent treatments. The ACA, on the other hand, did not prohibit balance billing. As a result, an out-of-network provider may still charge you the gap between what your insurance pays and the actual amount of professional services.

The ACA out-of-cost maximums also set a limit on how much you must charge out of cost for all of your medical expenditures each year. In addition, according to a 2018 ACA rule, health insurers must add your cost-sharing rates for some surprise bills against your out-of-pocket limit.

According to the Commonwealth Fund, states have a wide range of protections against surprise medical bills. But, 15 states do not have complete safeguards to avoid surprise billing, and 17 states do not have any protections.


The No Surprises Act will go a long way toward safeguarding you from surprise medical bills. This act requires physicians to reimburse you the same prices as your insurance would for emergency care and services at in-network health facilities.

Meanwhile, selecting providers in your insurance network whenever feasible and understanding your current state safeguards against surprise medical bills can prevent you from getting unexpected costs the best.

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I am a medical biller, a blogger and have 20 years of experience in medical billing, medical billing management, and medical assistant. My background includes positions as a clinical medical assistant, medical records technician, medical office manager, biller, and coder. I am certified by the American Academy of Professional Coders (AAPC) as a Certified Professional Coder (CPC) and by the Practice Management Institute (PMI) as a Certified Medical Office Manager (CMOM). As an office manager/biller/coder, I was a member of the Michigan Medical Group Managers, Michigan Medical Billers Association. I also served as a committee member of the Michigan Osteopathic Association of Practice Managers Education Committee.

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