Exorbitant medical bills have become a new reality for patients. Even when patients receive care in an environment characterized by low co-pays and deductibles, they find it difficult to adjust to high medical bills where out-of-network payments are becoming increasingly normal.
It is now common for patients to receive additional bills from out-of-network providers, even after settling their co-pays and deductibles. These additional charges come as a surprise as they believe their insurance companies should have settled what they owe to providers.
With surprise medical bills now attracting attention nationally, ASC’s want to develop strategies to protect their patients from them.
Growing Popularity of Surprise Medical Bills
Surprise medical bills arise because patients receive care from providers outside their networks, either in an emergency or for a procedure not offered by their in-network providers. Since these providers have no prior contracts with their insurance companies, they typically send additional bills to patients. In other words, patients are being balance billed.
Patients are however becoming increasingly aware of surprise bills and are not being quiet about it. This is evidenced in the growing media coverage on the subject which has created public awareness to protect other unsuspecting patients.
There is an increasing need for ASC’s to operate with patients within their network. This comes because of pressures from insurance companies who are also compelling their patients to receive care from providers that they have prior relationships with, to avoid high out-of-network payments.
The Complexity of Surprise Medical Bills
Despite these reactions, surprise medical billing has become more complicated and this calls for a proactive response from surgery centers to protect their patients.
Initially, surprise medical bills would only arise when emergency treatments from providers took place outside of the patient’s carrier network. This is no longer the case as patients today can still receive surprise bills even when their care comes from providers within their network.
This is because an ASC can be in-network while some of its medical staff are out-of-network. Providers can decide whether they want to be in or out-of-network. Take for instance an anesthesiologist who decides to stay out-of-network to receive higher payments than he would if he operated within the patient’s network.
These type of providers are referred to as “invisible providers”. They include anesthesia, pathology, and lab professionals. Patients typically pay less attention to the involvement of these professionals in their surgical care because they are more likely to build relationships with their surgeons or physical therapists when having surgery.
Even though ASC’s are making effort to ensure that these “invisible providers” are brought in-network, some remain out-of-network. This can pose a challenge for a surgery center as patients often hold surgeons and facility owners responsible for any surprise medical bills they might receive.
ASC’s must therefore be proactive to ensure that most of their ancillary professionals are brought in-network. Services rendered by those that can’t be brought in-network should be clearly communicated to patients.
Understanding the Legal Rules
Because of the public clamoring for protection against surprise medical bills, five states including California and New York have passed laws aimed at protecting patients. This trend is poised to increase in scope as two other states, Pennsylvania and New Jersey, are also on the verge of passing laws against surprise bills.
These laws have important features that ASC’s need to pay attention to. Laws can restrict what providers are permitted to charge patients for an out-of-network service. They can also require that patients be fully aware and give consent to receiving care from an out-of-network provider. In the event of disputes between providers and patients, the laws also make provision for the resolution of such disputes.
Providers operating in these states should ensure they understand these laws to avoid lawsuits. Even providers that do not have facilities in these states ought to take steps to ensure that patients are protected from surprise bills. Since ASC’s are known for providing high-quality low- cost treatment, a facility can easily lose patronage from patients if surprise billing is normal and not occasional.