The Surprising Billing Rule is nothing new, but thanks to a judge’s recent ruling, it might be a good time to take a fresh look at something you’ve likely gotten comfortable with.
We want to walk you through a refresher of the rule, some new provider-friendly developments, and look at some tips for providers like you to move forward as you consider both internal and external medical billing services.
What Is the Surprise Billing Rule?
The Surprise Billing Rule was introduced under the Biden-Harris Administration and intended to cut back on out-of-pocket costs for consumers that result from balance billing and surprise billing.
- Surprise Billing: When someone receives care without their knowing from outside their health plan network. This can happen for either emergency or non-emergency care.
- Balance Billing: This is when a provider charges an insured person whatever insurance did not pay. Both Medicare and Medicaid prohibit this.
The rule also bans:
- Surprise billing for emergency services, requiring that they be treated on an in-network basis with no requirements for prior authorization.
- Out-of-network cost-sharing for emergency and non-emergency services, so that cost sharing (like deductibles and coinsurance) can’t be higher than if services were provided in-network.
- Out-of-network charges without advanced notice.
- Out-of-network charges for ancillary care like an assistant surgeon or anesthesiologist.
The rule was prompted in part by the fact that two-thirds of all bankruptcies in the United States are linked to medical expenses. It sparked advice to consumers to promote awareness of their rights, advising them to ask providers to use in-network labs and to shop for better prices on tests and procedures. This new level of awareness has put additional pressure on providers to examine the way they bill, and even consider new approaches to medical billing solutions to keep up with consumer expectations and not violate laws .
What’s Happening Today
Healthcare revenue cycle management companies have been paying close attention since the regulations became effective for healthcare providers and facilities on January 1, 2022. The rules apply to anyone who has coverage through an employer, through the Health Insurance Marketplace, or through an individual health plan that’s been purchased through an insurer.
As things stand today, providers and facilities are required to communicate differently with patients. They are required to share easy-to-understand notices that clearly explain their billing protections as well as who patients should contact if they’re concerned that a provider or facility has violated the rule.
In the cases of patients that aren’t insured, most providers are required to provide a “good faith estimate” of costs before they provide non-emergency care. This has to include charges for the primary service or item. It must also include any other services or items that could be reasonably expected. If an uninsured or self-pay consumer gets a final bill that exceeds the good faith estimate by $400 or more, they have the right to dispute final charges .
Not long after the rule went into effect, news of a judge’s actions went public.
A federal judge in Texas recently ordered that key parts of the regulation be vacated, something many providers were happy to hear. The judge’s ruling centered on the regulations in setting up arbitration of disputes between payers and providers in managing out-of-network charges. Providers claimed that this was unfair and violated the intent of the law. The suit was brought by the Texas Medical Association against the Department of Health and Human Services (HHS) in October of 2021, with the argument that the regulation is unfairly biased toward insurers, giving them an advantage when establishing payment rates. The association also claims that the regulation on arbitration ignores Congress’ original intent of the law which was passed in late 2020.
What Can Providers Do?
As providers watch how the rule unfolds, they should continue to prepare with a few key pieces of advice.
Consider Operational Readiness
The law is already in effect, but providers can still take a step back and review their operations. This should involve considering analytics capabilities that will support any strategies that will help them avoid balance billing situations.
Train Your Staff
Providers should evaluate whether staff are ready to handle the new processes and procedures and look for opportunities where billers might need training. Some will need to consider the option to outsource medical billing and work with vendors to manage arbitration and other administrative processes.
Work on Consumer Outreach
Many providers are invested in giving patients a more retail-like experience, and the Surprise Billing Rule is another opportunity to do this. Consumers expect more transparency in pricing in healthcare, so provider education can step in. The benefit is that they will be building trust that can help strengthen relationships with their patients. At the same time, providers will be meeting the requirements that patients provide consent to out-of-network services that are more than in-network cost-sharing due according to their insurance plan.
Most importantly, providers should look at the resources and time needed to complete this type of plan. Many will want to rethink their medical billing services, and consider working with medical billing companies that are already well-versed in keeping providers in front of the No Surprises Rule. If you feel you want to take the first step in that process, start here.
 U.S. Department of Health & Human Services, “HHS Announces Rule to Protect Consumers from Surprise Medical Bills,” 1 July 2021. Available: https://www.hhs.gov/about/news/2021/07/01/hhs-announces-rule-to-protect-consumers-from-surprise-medical-bills.html.
 U.S. Department of Health & Human Services, “HHS Kicks Off New Year with New Protections from Surprise Medical Bills,” 3 January 2022. Available: https://www.hhs.gov/about/news/2022/01/03/hhs-kicks-off-new-year-with-new-protections-from-surprise-medical-bills.