WHAT HAVE WE DONE FOR YOU LATELY
Surprise !
BY DAVID WROTEN EXECUTIVE VICE PRESIDENT , ARKANSAS MEDICAL SOCIETY
The federal “ Surprise Billing ” Act went into effect on January 1 , 2022 . You have probably received correspondence from various carriers and management companies explaining your responsibilities . Needless to say , this new federal law is causing turmoil and confusion and has generated several lawsuits .
While I may be oversimplifying it , there are two primary targets of the legislation . As the name would suggest , the primary focus of the law is what we would all consider “ surprise billing .” This occurs most often when a patient receives services at an in-network facility , but during their stay receive services from an out-of-network provider or physician , unknowingly . For example , the hospital and surgeon are in-network , but they later find out that the pathologist or anesthesiologist was not in-network . They then receive a billing statement from the out-of-network physician for an amount above what their insurance company allows for in-network services .
The Act establishes a notice requirement for these situations , prevents collecting more than the in-network copay or coinsurance amounts from the patient , and establishes a dispute resolution or arbitration program to negotiate a fair payment between the billed charge and the in-network charge to be paid by the carrier .
Several lawsuits have been filed against this part of the bill because the federal agency charged with implementing the Act deviated from the plain language of the law in crafting their rules . In doing so , they created a situation where the arbitration companies would be required to give deference to the carrier ’ s median in-network payment . Of course , this would almost always result in the physician receiving less than their billed amount or even the UCR for the service . The language in the Act established several criteria for the arbitration review but placed no special weight on any one criterion . A lawsuit filed in Texas was successful in overturning the agency ’ s inappropriate
This occurs most often when a patient receives services at an in-network facility , but during their stay receive services from an out-of-network provider or physician , unknowingly . arbitration method . We are not certain exactly what that will mean for the remainder of the law .
The real “ surprise ” came in the form of another provision of this law that requires all health care providers to provide a “ good faith estimate ,” or GFE , of charges to self-pay patients when scheduling services or on request . This is not tied in any way to surprise billing or being in- or out-of-network . Our current understanding is that the GFE must reflect the cash price for services and the total cost of expected care furnished by the physician or provider during a “ period of care ,” which include other services likely to be furnished in conjunction with the primary item . The GFE must also include an itemized list and description of expected services , diagnosis codes , services codes , and associated anticipated charges .
This will certainly create more headaches for physicians and their office staff . We know that the federal agencies have provided sample forms to comply with the statute , and your AMS staff and legal counsel are continuing to study this new law and provide advice as soon as possible . ■
178 THE JOURNAL OF THE ARKANSAS MEDICAL SOCIETY