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A Small Step Forward on Surprise Medical Care “Balance-Billing”

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By @nicholas_bagley

The ME-P Back Story about a Decade Ago:

Link: https://medicalexecutivepost.com/2008/09/17/balance-billing-conundrum/

More on out of network Balance Billing a year ago and … today?

Per a rule released last year, CMS will now require qualified health plans to count the cost sharing paid by the enrollee for an essential health benefit. But, what about today?




 A small step forward on surprise billing


We’ve written about this problem before on the ME-P; and we now appreciate this guest ME-P update.

More: Balance-Billing Conundrum


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12 Responses

  1. AMA: Top 5 Medical Billing Denials

    1. Missing information
    2. Duplicate claim or service
    3. Service already adjudicated
    4. Not covered by the payer
    5. Limit for filing expired

    Source: Advance Web


  2. Dear Dr. David,

    The Affordable Care Act made sure that no individual could be denied health coverage due to a pre-existing condition. Last fall, the Trump administration issued guidance that weakened this provision of the ACA. Fortunately, this afternoon the U.S. House of Representatives will consider legislation that would revoke the administration’s efforts to undermine these important protections.

    Contact your representative TODAY and urge them to vote yes on H.R. 986, the Protecting Americans with Pre-Existing Conditions Act of 2019! This is a critical step towards ensuring that all Americans have access to comprehensive, affordable health care.

    Gaby Witte
    Senior Manager of Government Relations


  3. Balance Billing

    What It Is and Why Trump Wants to Get Rid of It?

    Dr. David E. Marcinko


  4. 42.8% of ED Admissions in 2016 Incurred Out-of-Network Charges

    JAMA Internal Medicine recently published research on out-of-network charges for hospital inpatient and emergency department (ED) admissions. Here are some key findings:

    • From 2010-2016, out-of-network billing increased from 32.3% to 42.8% of ED visits.
    • The mean potential liability to ED patients increased from $220 to $628 from 2010-2016.
    • For inpatient admissions, the incidence of out-of-network billing increased from 26.3% to 42.0%.
    • The mean potential liability to patients increased from $804 to $2040 for inpatient admissions.

    Source: JAMA Internal Medicine, August 12, 2019


  5. Update on BB
    [AKA surprise billing]


    Dr. David E. Marcinko MBA


  6. MORE on BB


    Dr. David E. Marcinko MBA


  7. 12.3% of Pathologist Care at In-Network Hospitals Was Billed Out-of-Network

    Health Affairs recently published an article on out-of-network billing among specialists at in-network hospitals for a large commercial insurer. Here are some key findings from the report:

    • At in-network hospitals, 11.8% of anesthesiology care was billed out-of-network in 2015.
    • 12.3% of care involving a pathologist was billed out-of-network in 2015.
    • For radiologists, 5.6% of claims at in-network hospitals was billed out-of-network in 2015.
    • 11.3% of cases involving an assistant surgeon were billed out-of-network in 2015.

    Source: Health Affairs, December 16, 2019


  8. BB Strategy?

    Dr. David E. Marcinko MBA


  9. CMS

    CMS has announced today that providers should continue to use the current ABN despite the March 2020 expiration. A new form is currently awaiting approval and should be released later this summer, which should be good for 3 years.

    Dr. George


  10. 2 in 3 Privately Insured Adults Have Received an Unexpected Medical Bill

    The American Heart Association recently released survey results on unexpected medical bills. Here are some key findings from the report:

    • Half of U.S. adults say worrying about an unexpected medical bill keeps them from seeking care.
    • 44% say they would not have the money for an unexpected medical bill for $1,000.
    • 2 in 3 U.S. adults with private health insurance have received an unexpected medical bill.
    • Of those, 33% were not able to pay the bill with money immediately available to them.

    American Heart Association, November 30, 2020


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