The No Surprises Act: a silver lining for patient engagement

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When I was pregnant with my first child, I needed a prenatal test which could only be done in the hospital. Not knowing if the procedure would be covered by insurance, I spent days calling area hospitals to inquire about the costs. After all of this effort, I received a list of billing codes from a hospital’s patient financial services department and instructions to call my insurance company to see how much they would pay so that I could then calculate my out-of-pocket expenses. .

Exasperated, I gave up and decided to take the test at the most reputable hospital and closed my eyes, waiting for a sky-high bill to arrive in the mail months later. Fortunately, my employer’s insurance plan covered most of the costs.

Health care is one of the only purchases people make without knowing the upfront cost. Until recently, as my own example illustrates, people in need of care had virtually no way of knowing their expected out-of-pocket expenses before deciding on care, and often received expensive and unexpected medical bills after the fact. With the Law without surprise, which will come into effect on January 1, 2022, healthcare providers have an opportunity to address this issue and build a closer and more confident relationship with their patients in the process.

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It’s not just emergencies

Much of the discussion of the No Surprises Law centers on people who visit a network hospital in an emergency and receive care from an off-network provider, such as a doctor or laboratory. While hospital costs are covered by insurance, charges for out-of-network services may not be covered and may result in high charges that people with health insurance would not expect.

This was the fate of Phil Gaimon, a hopeful Olympic cyclist who received a $ 200,000 note for shoulder surgery following a bicycle accident. Gaimon had two different insurance policies, neither of which agreed to pay the full cost of care because the providers were out of the network.

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The No Surprises Act prohibits these so-called surprise bills, but also goes beyond the emergency department and opens the door for hospitals, doctors, labs and the like to engage patients as clients who can make choices based on what they can afford.

As of January 1, the law requires health care providers to advise patients of their right to receive an upfront price in the form of a good faith estimate of expected charges for all services that should reasonably be provided before. that the services are provided. program. This includes the cost of services provided by all health care providers involved in the care, whether or not they are part of the same health system or practice.

The good faith estimate must be provided to uninsured or self-paid patients upon request, and must include self-paid or cash prices. Estimates for people with health insurance should include the price of the insurance plan. And all estimates must include available discounts and be provided prior to service planning.

For example, before a person has knee surgery, the health care provider planning the operation must provide the patient with an estimate of the charges for the hospital or surgical center, anesthesiologist, services. imaging, medications and all follow-up visits. This allows patients to find the lowest cost by comparing estimates.

In its release from No regulation of the law on surprises, the government said the purpose of the law is to provide patients with “more choice, better service and lower prices.” In other words, the government is telling health care providers that patients are consumers. Suppliers must listen.

Take the chance

Not only does this disrupt the paradigm in which patients buy health services without knowing the costs, but it forces communication about those costs among all parties that might be involved in a procedure: hospitals, community providers, pharmacies, laboratories and others. patient. Small providers, such as clinics or doctor’s offices, may not routinely serve self-paying patients, but will now have to develop cash prices.

The No Surprises Act also requires that good faith estimates include estimated drug costs, which is an entirely different – and more complex – discussion. But these challenges also create opportunities to better understand patients and their financial situation.

Addressing financial issues up front, before care is delivered, creates opportunities for providers to avoid unpaid medical bills, reduce bad debts, and improve revenue cycle performance. It can also improve the patient experience (and help develop trusting relationships with their providers). Armed with knowledge of a patient’s financial situation early on in care, providers can identify lower-cost options and offer payment plans or credit programs to help patients avoid unexpected financial disasters. In short, the challenges of implementing good faith estimates, as required by the No Surprises Law, should be seen as an opportunity to bring healthcare into the consumer age.

Stacy Bratcher is Vice President and General Counsel of Cottage Health in Santa Barbara, California.


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