What is Surprise Billing?
Surprise Billing, or other wise known as out-of-network billing is getting a lot of press recently in the current election. The reason it’s getting so much attention is due to the effect that it has on consumers. The fact of the matter is that it’s the consumer which causes the problem for the most part. Insurance is super complicated no doubt, but you either see providers in-network, or out, and either the in-network providers only order test or procedures from other in-network providers, or they don’t. Surprise billing happens when a procedure, test, or other healthcare service is ordered out-of-network and then the subsequent healthcare claim gets underpaid or not paid at all. The result of this underpayment or non-payment leads to the patient/consumer on the hook for the bill. But how is this fair?
Joe wants to end Surprise Billing
For the most part it isn’t fair, but people aren’t very bright and never ask questions in the first place. If you plan on receiving healthcare, you really should understand your coverage options and the cost that will be incurred. If you do not have healthcare coverage and require care, don’t just visit the local urgent care or emergency room. State sponsored healthcare is available in most metropolitan cities throughout the country. It doesn’t mean you won’t pay anything, but it’s the most cost efficient option if you are not in an emergency situation. The fact is that there is little to no consumer education on healthcare availability and health insurance. So then why does it still exist?
Why does Surprise Billing still exist?
Surprise billing still exist because healthcare providers are keen to the fact they get paid more billing claims out-of-network versus in. Until the amounts on out-of-network claims get adjusted, surprise billing will always exist. Most consumers aren’t aware that medicare will pay $85 for a specific CPT code, where as a united healthcare plan with out-of-network benefits could pay up to 10x the amount for the same CPT code. Not all healthcare providers take advantage of surprise billing, in fact quite the opposite. A solid communication strategy with patients will help most healthcare providers avoid surprise billing. By using a third party company to assist with Accounts Receivable Management, providers can have a peace of mind that their claims collection process is compliant. So what if surprise billing happens to you?
Caught off guard by a unexpected medical bill?
First off, don’t panic! Even if Joe does win, I can assure you it will take a while for legislation to be put into place. Ask yourself whether I am being sent the bill from a collection agency or the original healthcare provider. If you’re being sent a statement from a collection agency, it’s best to ask for proof of what you owe. Once you have proof, compare the proof to the insurance explanation of benefits from the time. Make payment arrangements as soon as possible. Do not avoid the collection agency, as they will most likely report it to your credit and it will have a negative effect after some time frame. If the dollar amount is large enough, a collection agency can take you to court. It is always best to communicate and validate the debt that is owed. What if the statement is from the provider themselves?
Okay so here’s how this all works. Most providers billing healthcare claims choose to bill at a multiple of medicare. What does that mean? Let’s say medicare pays $100 for a particular CPT Code, you can for example sakes say the CPT Code is equal to a single service. So if a service cost $100, the healthcare provider bills say 3x the amount or $300. When the provider receives less than $100, the default is for a bill to go out for the balance. Legally they are required to send you at least two statements for any balance on your account. Some providers are actually trying to capture the whole $300, but many times they don’t have the bandwidth to do it, so they settle with what they get from insurance and never collect on you. In Conclusion, check the statements closely and always communicate.
Laws to protect consumers
The medical debt relief act of 2020 is currently in the senate and will most likely sit idle until after the presidential election and subsequent senate and house elections. One proposed law is that consumers would have one year to resolve a medical debt after being made aware of it.
Fore more information on health care related topics, check out our other articles:
- The Evolution of a Medical Collection Agency
- Medical Payment Data
- Receivable Management Services For Medical Providers
- Paid to Patient Insurance Claim Recovery
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