“Surprise billing” is a phenomenon in which patients receive bills that are either higher than anticipated, or contain charges that they did not expect and were not informed of prior to treatment.
Typically, this happens because a patient receives treatment, then finds out that one or more providers involved in treatment fell outside of the insurer’s coverage area. For example, if a patient undergoes surgery and requires anesthesia, but the anesthesiologist isn’t covered by the insurer, the patient could receive a higher bill than anticipated.
To remedy this, the Center for Medicare and Medicaid Services proposed a rule that aims to resolve the issue.
Reviewing the CMS Rule
Toward the end of last year, CMS proposed a rule that will take place in the 2017 benefit year, designed to address cost sharing.
Specifically, CMS said:
“We propose that issuers must count the cost sharing charged to the enrollee for certain out-of-network services (provided at an in-network facility) towards the enrollee’s annual limitation on cost sharing. This proposal aims to limit ‘surprise bills’ to consumers.”
Furthermore, CMS said that an exception will be applied only if the issuer “provides 10 days’ notification to the enrollee that an out-of-network provider may be providing these services and that the enrollee may incur additional costs.”
This proposal, if enacted, would go a long way toward limiting surprise billing, which would help patients and reduce some of the ire insurers have drawn from angry consumers.
The Impact on Anesthesia Billing and Coding
This could have an indirect impact on anesthesia billing and coding because anesthesia providers are most frequently involved in some of these cases that prompted the new ruling. Patients understand how their primary care providers and surgeons are in-network, but they aren’t always familiar with the occasional out-of-network status of anesthesia providers.
Anesthesia billing and coding specialists may not have to change anything directly as a result of the ruling, but it is something providers need to be aware of as they head toward the 2017 billing year.