When employees get sick or injured, the last thing they need is a jolt to the heart when the bills start rolling in. New federal protections through the No Surprises Act aim to reduce this, but plan participants must still know how to navigate the system to avoid surprise medical bills. Employee advocacy provides essential support.
Effective 2022, the No Surprises Act (NSA) bans surprise billing for emergency services; bans out-of-network charges for ancillary care (like an anesthesiologist or assistant surgeon) at an in-network facility in all circumstances; and bans other out-of-network charges without advance notice.1
Understanding Surprise Billing
Americans are undeniably concerned over medical bills—67% of adults reported worrying about unexpected medical bills and 33% of insured adults reported receiving a bill for a service they thought was covered.2
It’s common for patients to receive care from out-of-network providers at an in-network facility. One nationwide analysis found that 16% of in-network inpatient admissions result in at least one out-of-network charge. For some states, this average was even higher: New York (33%), New Jersey (29%), Texas (27%), and Florida (24%).3
The NSA should reduce this in many instances; however, if a plan participant unknowingly chooses an out-of-network facility or provider, that bill may still be “surprising,” but it wouldn’t be illegal. Likewise, many providers may wrongly issue “balance bills” for services that should be covered under the NSA. Do your employees know what to do in these situations or have appropriate support to deal with them?
Under the NSA, as long as the facility chosen for the procedure is considered in-network, all services provided should be billed as in-network. “Should be.” This doesn’t guarantee that all services will be billed accurately and appropriately. This could expose patients to additional, and sometimes huge charges. Such bills shouldn’t be paid before being investigated by an insurance expert, but are you confident that your employees understand this?
Enter Employee Advocacy
A strong employee advocacy program can help plan participants navigate a high medical bill and work to ensure that a participant only pays what they should.
These specialized benefits advocates can also help participants review their insurance plan before a procedure to determine what the plan will pay. Figuring out who is and who isn’t in network ahead of time is critical to keeping the cost down.
Advocates can “pre-educate” employees on what care is covered and which facilities will take their insurance. They can help employees get an estimate of the cost of medical treatment before it’s delivered. Many carriers have online cost estimator tools where employees can see how much they’ll be responsible for. Doctors can also provide an estimate and detail the specifics of a procedure, as well as answer patient questions ahead of time. It’s a good idea for the employee to gather written cost estimates in advance.
If the bill comes in much higher than expected, the benefits advocate can investigate. The bill could be coded improperly, the insurance payment may not have been credited appropriately, or the bill itself may run afoul of the NSA. Benefits advocates research a surprise medical bill and cut through the red tape to get answers from carriers and providers faster than employees. Employee advocacy teams often have a direct line to carrier decision-makers and providers that an employee wouldn’t have access to.
The healthcare landscape continues to get more complex, all while putting more responsibility on individuals to understand their insurance options and make educated decisions. Employee advocacy can turn insurance users into savvy insurance consumers, long before they pass through the sliding doors of an emergency room.1 U.S. Department of Health & Human Services, “HHS Kicks Off New Year with New Protections from Surprise Medical Bills” 2 Kaiser Family Foundation, “Data Note: Public Worries about and Experience with Surprise Medical Bills” 3 Peterson-KFF Health System Tracker, “An Examination of Surprise Medical Bills and Proposals to Protect Consumers from Them”