Surprise Bill Obligations

By | January 25, 2018

NYS and other states have implemented regulations referred to as “Surprise Bill Regulations” to address a consumer demand for transparency as to healthcare providers participation in health plans. Simply put, providers, all providers, are required to post what health plans they are contracted with and participating, advise patients what their economic exposure is if they are not par with a patient’s plan, and refer to other providers also in a patient’s plan.

While it sounds like a lot of extra work it’s a good exercise, even if you were not required to do so. Post the plans in your office, post them on your website, and provide a written notice, for patient signature acknowledging the patient’s responsibly – economically, if you are out of network.

In reality its not that hard, and compliance should not be a material burden. You and your staff after all, should be well aware of the plans and products that you do participate with. If not, confirming which you are in, and which you are out. Getting clear the plans you par with will improve your receivables management.

You can simplify your referrals by assuring your usual labs and other ancillaries are par with the plans you par with as well. As for your referrals to other physicians, build yourself a matrix of your frequent referral receivers and the plans they claim on their websites that they par with. In doing so, you actually are meeting a contract obligiaotn of every health plan you par with, which has always required you to restrict your referrals to other par providers. Some payers have been terminating physicians that routinely refer to non-par physicians/providers as their prune their networks. So, think of this effort as self-protection of your participation.

As you check on the participation status of your usual receivers of referrals, don’t fall into the trap of accepting “we take all insurances”, or well take all your patients, and your patients will never be billed. This may mean that what that provider is doing, and this technique is rampant with non-par labs, is they will bill the insurance of the patient, even if they are not par, and then write off the balance of the bill not paid. While it may seem like they are doing your patient a favor, and making it easy to keep referring to them, they are setting you up to take the fall for referral to a non-participating provider. Data analytics of any payer will identify you as the source of these out-of-network referrals, which often come at extraordinary charges. For non-physicians that you refer to, labs, physician therapy, and the like, ask them for a list on their letterhead of the plans that they are contracted with – this is your get out of jail card if a payer take issue with your referrals.

The entire exercise, keeping care within the patient’s plan network is good for the satisfaction of your patients. Nothing negatively impacts a patient’s relationship with a physician than a physician that puts them in economic harm’s way by referring them to a non-par physician exposing them to costs not covered by their insurance.

If you have to break a long-standing referral relationship because that provider is not par with the plans you participate with, you are doing so to protect your patients. Few physicians want to add hurt to illness by adding a financial burden on top of the burden of illness.

Author Bio:
Alex Tate has been part of the healthcare Industry for over 6 years. He has been writing and analyzing content pertaining to healthcare. His particular specialty is regarding his research and works regarding specialized EHR. Specifically Oncology EHR.  His belief in technology, compliance and cost reduction have opened new horizons for people in the health care industry.