Despite having medical insurance, more than 100 million Americans are legally not protected against costs arising from out-of-network providers; that is around 40% where the insurance company covers lesser costs than the patient expects. For the same reason, "End Surprise Billing Act of 2017" has been introduced in the House, as an amendment to title XVIII (Medicare) of the Social Security Act and demands that hospitals which are a part of Medicare, must meet certain criteria while billing patients for out-of-network services.
Usually, when a patient visits a hospital to get a procedure performed, he/she is covered under health insurance. But this becomes a nightmare when the patient and his family realize that parts of the procedure were performed in an out-of-network capacity and they are left with huge amounts of unpaid bills. And these out-of-control costs are to be paid from their own pockets. For the same reason, lawmakers in the US are looking towards providing medical billing protection for patients via legislation to be approved. The senate plans to set the rules for billing and reimbursement which intends to set a limit beyond which hospitals cannot charge the patient even if there is no existing contract with a health insurance agency. On the flip side, doctors are concerned as procedures performed in emergency cases/rooms could be difficult with limits set or even so in cases where it is a planned procedure.
Surprise bills can occur anywhere - in-network facility, hospitals, ambulatory care services, or where some assistances/contracted providers such as anesthesiologists, emergency rooms or surgical room assistants who regularly don't take part in all procedures. Sometimes, these are not part of the network in the insurance plan as that of the procedure. This is where the costs can rise without any estimation thereby giving the consumer added costs. Other cases where the consumer can be weighed down with added costs are when any lab related services such as ultrasounds are sent to radiologists or lab companies that are out-of-network, and finally in cases of mismanagement when provider directories do not hold the latest list of in-network providers.
For Americans, the 'End Surprise Billing Act' addresses the need to end 'surprise billing.' For patients seeking medical services and are insured, this act not only prevents surprise medical bills, but it also mandates that all hospitals which are a part of Medicare must be transparent with their billing procedures and inform the patients about out-of-network providers well in advance. It requires that hospitals must make available two written notices to the insured consumer about the hospital/physician/participating provider being an in-network provider, and other additional out-of-network charges for the services planned as per the individual’s health care coverage plan. Once the notice has been sent, the hospitals must obtain a signed and knowledgeable (informed) consent from the consumer at least 24 hours before the scheduled service. The act further prohibits providers if they do not provide the notice and abstain from charging additional (if the provider was in-network). Finally during emergency cases, providers will be prohibited from charging additional, and must charge the actual amount as that of the in-network/participating provider cost of the services rendered.
Though many times, added billing costs are unintentional, it is by no means less stressful for the patient to pay from pocket. Protection for consumers against hefty bills needs to be considered in full capacity to prevent frauds and provide peace from surprise hospital bills to the patient and his family during a hospital visit. It is imperative for any country to protect consumers from financial adversities especially in cases of medical requirements.
