Tammy Hawes is CEO and Founder of Virsys12, a Salesforce Consulting and Appexchange Partner focused on healthcare technology transformation.
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As of January 1, 2022, patients are supposed to have new protections from surprise medical bills thanks to the implementation of the No Surprises Act. These surprise medical bills usually occur when, unbeknownst to the patient, a hospital-based service is provided to a patient by a provider who is not part of their insurance company's approved network of providers. Such out-of-network charges can add up to many thousands of dollars and are a very unwelcome surprise.
According to the Kaiser Family Foundation, surprise bills happen in about one in five emergency room visits and between 9% and 16% of hospitalizations for non-emergency care. Surprise bills typically come from hospital-based providers who have no relationship with the patient, such as pathologists, anesthesiologists, radiologists and emergency room physicians (PAREs).
The Challenges With The No Surprises Act
Though the No Surprises Act promises significant protection to unwary patients, the reality is that most patients may not benefit much from this new law because of the hoops they must jump through to take advantage of it. Since the No Surprises Act only applies to "emergency care, post-stabilization care, and some types of non-emergency care," this includes things such as getting cost quotes from providers that most patients do not know are involved in their care, knowing exactly what charges their insurance coverage is supposed to cover, how their deductible is applied, where they stand in regard to their out-of-pocket maximum and other byzantine details of the typical healthcare insurance plan.
The fact is that most people understand very little about how their health care coverage works. As a result, they have no way of knowing if the charges they incur are legitimate or not. Without this knowledge, they will not be able to take advantage of the protections afforded by the No Surprises Act.
On top of this problem, the No Surprises Act does very little to deal with the opacity of communication built into the health care billing system. For example, every health insurance payer negotiates separately with every healthcare provider group, and the patient and the hospital might not know the status of these negotiations—and hospital privileges are not tied to an insurance company's willingness to work with a particular provider.
This means that, for example, an anesthesiologist whose contract negotiations break down with an insurance company will still have privileges at a hospital that is in a patient's network. When the patient shows up at the hospital for a surgical procedure, the anesthesiologist would provide services on an out-of-network basis without the patient's knowledge and the patient receives a bill for services they thought were covered by their insurance plan.
Only the most healthcare-lierate patient would know to ask in advance which in-hospital services are covered by their health insurance plan or would know how costs should be mitigated by their deductible or out-of-pocket maximum.
Even if a highly literate patient knows to ask about these kind of charges in advance, it is highly unlikely that a hospital would be able to provide an accurate advance estimate of what the patient's procedure is likely to cost. As odd as it may sound, because of the many variables involved—such as tracking supplies used, operating room time, the number and types of providers involved, plus the details of an individual's health care plan—most hospitals would probably find it impossible to tell you in advance what your procedure will actually cost.
How Technology Can Help
America needs a big push for health care literacy, but the likelihood of that happening is close to nil. As is the case with many of our society's most intractable problems, the solutions may lie with technology, such as a complete health care provider network directory, i.e., a list of all providers covered by an insurance company that includes in-hospital PAREs providers, who are typically not part of provider directories.
Having such a complete directory would solve half of the problem. To solve the whole problem, it would also need to be interactive and fully integrated with data from both the health care plan and the hospital so that:
1. Everyone would know in real time whether or not a particular PARE provider is in the health plan's network.
2. Patients would know which PARE providers are required for any particular procedure. For example, in such a provider directory of the future, a patient would automatically be notified that their upcoming procedure will involve an anesthesiologist and a pathologist and that both are in-network.
Finally, if the provider directory were synced with the patient's health care plan, then the patient would know in advance, based on the specifics of their coverage—including how much deductible and out-of-pocket maximum applies—the total amount they will owe.
This kind of technological solution would truly bring no surprises in health care. Until we get there, American health care consumers are likely in for some unpleasant surprises for a non-trivial percentage of the time they receive hospital-based care.
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