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Surprise Out-of-Network Bills: Preparing for Potential Legislative Changes

Jonathan G. Wiik
Blog Post07/24/2019
Surprise Out-of-Network Bills: Preparing for Potential Legislative Changes

While out-of-network (OON) medical bills aren’t a new phenomenon, they’ve come under heightened scrutiny as patients are paying more for healthcare. Congress has taken note, and current legislative efforts are underway to help put an end to these surprise medical bills. The bipartisan STOP Surprise Medical Bills Act has passed in the Senate Health, Education, Labor and Pensions (HELP) committee, and is onto the Senate floor for vote.

While this bill is being met with mixed reception from healthcare providers and payers, it’s being discussed in Congress and has a chance to pass both houses and become law. Below is my insight on some key questions around the bill.

How do OON bills affect patients?

Patients want more transparent healthcare pricing. As they shoulder more costs, an expensive, surprise OON bill can be overwhelming and stressful. These bills are common and often occur when a patient:

  • Can’t determine if a provider is in or out of network (especially in complex cases) in advance of service
  • Isn’t in a position to choose their provider based on coverage (notably in emergency care situations)

According to a KFF analysis, nearly one of every six emergency room visits and inpatient hospital stays in 2017 led to at least one out-of-network healthcare bill.

What can providers expect?

Along with the principles outlined by the American Hospital Association in its testimony, there are some specific things providers will want to consider in regard to this legislation, including:

  • Rate and benefit caps – Adjust billing statements to reflect capped fees and copayments
  • Notification requirements – Show network status of ALL providers in each care episode
  • OON benefits/estimate calculator – Provide a clear estimate of OON coverage and benefits

What can providers do to prepare?

While many providers may be addressing OON bills with condition of admission and/or consent to treat documentation, there’s more to be done and room for improvement. As this bill goes for debate, patient protection and notification requirements may become mandatory at the encounter level (each visit). Tightening up the following processes can help:

How can TransUnion Healthcare help?

As regulations evolve and place more requirements on providers, it’s important to have a comprehensive picture of patient benefits to minimize surprise billing. The right data helps the patient, provider and payer better understand where benefits can be applied contractually, and facilitates a more transparent billing experience.

TransUnion Healthcare leverages data and technology to successfully identify out-of-network patient encounters. See how our comprehensive Patient Access solutions can help ensure better patient care and improve the patient financial experience.

Jonathan Wiik currently serves as a Principal of Healthcare Strategy at TransUnion Healthcare. He has over 20 years of health care experience, is a published author and frequently speaks at national events and conferences.

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