According to a 2011 analysis by Health Services Research, almost 10 percent of privately insured individuals have used out-of-network providers, and 40 percent of those individuals received “surprise medical bills,” a term known as balance billing in the healthcare industry.
Another report by Consumer Union shows that nearly two-thirds of privately insured Americans will fight these surprise bills, often leaving the burden of collecting these legal bills on the physicians.
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Learn What Balance Billing Means for Emergency Medicine
In Florida, the House Insurance & Banking Subcommittee approved HB 221, the balance billing proposal aimed at protecting patients from surprise charges when they receive emergency healthcare.
As you are likely aware, there is a great deal of political strife between providers and payers over reimbursements, and patients are stuck right in the middle. Let’s discuss the current state of balance billing and what it could mean for your collections
What Is Balance Billing?
Balance billing, or surprise medical bills, are when providers send patients a bill because the entirety of their services were not covered by insurance companies. This often occurs when a patient needing emergency care visits an in-network emergency department but is treated by physicians who are out-of-network.
Out-Of-Network Physicians In In-Network Hospitals Can Expect A Fight From Payers
Clearly, patients do not voluntarily visit out-of-network providers. However, the reality is that most of these services are provided by emergency care physicians, often in situations where patients have no time to assess insurance matters in life-or-death situations.
Because many hospitals use contract-based or outsourced emergency physicians, patients find themselves getting a bill from out-of-network physicians that provided them care at in-network hospitals. As these physicians are unable to resolve the billing problems with insurance providers, the bills are passed on to unsuspecting patients.
The nation’s largest insurer, UnitedHealthcare, has publicly stated they won’t pay the bills of out-of-network emergency physicians even if they are working for in-network hospitals. The buck, quite literally, is passed to the patient.
Going After Collections From Insurance Companies May Result In Legal Warfare
As health insurance provider Aetna has shown, lawsuits aimed at physicians are not out of the question. In New Jersey, they sued six out-of-network physicians for allegedly over-charging medical services and have formed a lobbying firm to help what they call “price-gouging.”
Expect Consumer Education To Remain Low On Balance Billing
Out-of-network care will likely continue to be a trend amongst emergency providers even with the risk of insurance lawsuits and patient uproar. Patients don’t often have the opportunity to select an emergency room when riding in an ambulance, and even if they are taken to an in-network hospital, the entire emergency department may be comprised of non-participating physicians.
The Affordable Care Act (ACA) sought to shed light on out-of-network costs to those registered, but the data that might help these patients has not yet been published. Therefore, expect that patients are unlikely to be aware of the effects of balance billing before care and are more likely to try to refute, or negotiate, with emergency care physicians, after the fact.
Balance Billing Could Be Eliminated In 2017
States are trying to fill the gaps between insurance companies and providers so fewer patients are left with surprise bills. Florida is one of many states that is proposing independent dispute resolution, although there is a bit of concern from physician and hospital-based groups due to the language on insurers only being responsible for a “reasonable reimbursement.” Clearly, the definition of reasonable needs to be more specific to avoid further dispute should the proposal move forward.
Rep. Carlos Trujillo, R-Miami, wants to put an end to balance billing with HB 221. Trujillo says that PPO members are usually victims of balance billing, and if they are unable to pay the bill may end up filing for consumer bankruptcy.
What Is HB 221?
Under Trujillo’s HB 221 proposal, the following has become mandatory:
· Hospitals are required to post information on the insurance plans they accept in the preferred provider network on their websites.
· The bill provides clear information on the implications of selecting an out-of-network provider (for insured patients).
The proposal has not come without conflict; physicians, hospitals and other parties related to emergency care feel that it creates more costs for them long-term. They also feel more blame should be placed on the insurance companies, who they feel don’t properly compensate for the costs and force physicians to pass the bill to the patient.
Simplifying Collections With An Emergency Billing Company
The New England Journal of Medicine published a study showing that more than 20 percent of patients who received emergency care in-network still received treatment from an out-of-network doctor. Thus, these patients were all billed, on average, $622, in balance billing charges.
While the above is troubling, there is some hope for emergency medicine providers. At DuvaSawko, we understand the troubles emergency department physicians face with balance billing challenges, and we can support clients with financial data. Here’s just a couple of ways our financial data services are working to serve you:
1. Measuring the financial impact leading to necessary cash flow changes and budgetary adjustments.
2. Financial Impact of lower revenues requires staffing changes that are more cost efficient using our staffing model.
And we are working with lobbyists to tackle the U&C (Usual & Customary Rate) issue at the state levels as well as the national levels by participating on the ACEP Reimbursement Committee and EDPMA as a data source.
Contact DuvaSawko today to have a complimentary practice analysis and see how we can help you today!
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