Older Adults Avoid Surprise Medical Bills – Insurance Disclosures

For far too long, insured patients were in the dark about how much a scheduled health operation would cost them. Consumers could attempt to obtain a broad estimate of how much their health insurance would cover for the type of surgery they anticipated having, or they may utilize online calculators to evaluate typical costs charged for comparable operations.

Medical billing, on the other hand, has long been opaque; in fact, only after the treatment was completed did detail like what services were utilized and who was involved in their treatment becomes available. Importantly, patients frequently had no idea if those providing care were inside or outside their health insurance plan’s network of providers, necessitating them to pay more.

Consumers were sometimes unaware that a provider who was involved in their care was out-of-network, resulting in hundreds or thousands of dollars in charges that they could not have predicted.

The No Surprises Act, which became law on January 1, 2022, bans surprise medical billing in emergency and certain non-emergency situations, protecting customers from potentially large out-of-network bills they don’t expect. The lesser-known aspects of the legislation requiring providers and insurers to give consumers essential cost information before their care are also essential.

Information at Hand

The No Surprises Act, which amended the Health Insurance Portability and Accountability Act (HIPAA), also addressed several additional topics. In addition to the main provisions of the HIPAA, The No Surprises Act ensures that patients are informed about a provider’s cost, services, and network condition ahead of time during a planned episode of care.

Before receiving services from an out-of-network facility or provider, a consumer must be informed of the network status of the facility and all providers who will participate in the treatment.

The notice must also include a good-faith estimate of the amount that an out-of-network practitioner or facility will charge for services, as well as information on any user management requirements.

Providers must also give the insured person wrote notice (unless the individual selects to receive it by e-mail) at least three days before their appointment or three hours ahead of same-day services.

An insurance company’s enhanced explanation of benefits (EOB) — An insured person who schedules a health care service in advance will receive an advanced explanation of benefits (EOB) from their health insurer.

The first part of an advanced EOB should include details on the provider’s or facility’s network status, the good faith estimate of charges for the items or services, and any relevant usage management requirements.

The second part of the claim needs to contain an estimate of anticipated consumer cost-sharing as well as the amount that the insurance will pay and the amount that has already been paid toward deductibles or out-of-pocket maximums.

Because of the complexity of placing this requirement on insured customers, the federal government has delayed enforcement of the advanced EOB until after future rulemaking.

Making Disclosures Meaningful

The No Surprises Act, which took effect on Jan. 1, 2020, requires new advance information disclosures in response to an increasing number of instances when patients are harmed or left dissatisfied because their providers failed to provide timely and accurate treatment information as outlined in Medicare regulations. These new advanced knowledge disclosures will give significant and immediate cost transparency, allowing consumers a bigger.

Unfortunately, we understand that simply providing the information isn’t enough to stop people from incurring high medical expenditures. Surveys have revealed that insurer communication to consumers is often opaque, either failing to reach them or being buried in thick documents. Consumers frequently struggle to utilize cost data for them to reduce their costs.

As a result, making these two new announcements into protections against surprise medical expenses will require enormous efforts by all stakeholders, including physicians and insurance companies that provide information.

The bill’s authors have also maintained a public presence and made multiple trips to the capitol in recent months to advocate for passage. The legislation, however, has not yet advanced beyond the House of Representatives; it will need further work in both chambers after reaching the governor’s desk, where additional changes are likely.

Stakeholders must develop disclosures in a way that best protects and informs customers, including providing consumers with clear, concise, and accessible information regarding costs and care.

Given the difficulties many people have in paying for healthcare, disclosures relating to expenses that are shared with customers should stand out amid the flood of other information they receive and include a clear method for them to ask questions.

Avoiding surprise medical expenses relies on consumers having correct and timely information to make an informed decision. Provider and insurer notifications under the No Surprise Act are designed to give consumers the information they need, allowing them to avoid surprise medical expenses.

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Disclaimer: We are not associated with the MyAARPMedicare or MyAARPMedicare.