Healthcare cost transparency strategies that align with the evolving No Surprises Act

John Talaga
John Talaga
is the Executive Vice President and General Manager in Healthcare.

Last year around this time, I wrote a couple of blogs on the No Surprises Act, federal legislation designed to protect patients from surprise bills for healthcare outside of their insurance network. Providers are required to present “good-faith estimates'' in advance of treatment for all costs. The idea is that patients more informed about their financial obligations can make better decisions, benefiting themselves and the entire healthcare ecosystem.

I pointed out then that there are a lot of unknowns that the No Surprises Act can’t account for. As a consumer or business, we typically know what is being bought and how much a purchase will cost in advance of making a commitment to buy. In healthcare, that’s not the case. It’s rare that the patient or provider knows everything needed at the time of visit, especially if there are unforeseen complications.

Two recent stories highlight continuing challenges around cost transparency between patients, providers and insurers.

In Washington state, a Seattle woman had an emergency related to a complication with her pregnancy, which required an extended stay in the hospital. Another emergency post-pregnancy complication required an additional outpatient procedure. Fortunately, both baby and mother are healthy, but much to the mother’s surprise, neither emergency was fully covered by her health insurance, meaning she received two unexpected bills for over $135,000. You can read the full story here.

This is clearly an outlier – a result of some ambiguity over what is considered “emergency care,” and how some states define in-network and out-of-network providers. But it is also exactly the type of situation the No Surprises Act is designed to prevent. I’m glad to say (spoiler alert) that, after a lot of back and forth, it has all been worked out between the insurer, the hospital and the patient, with the insurer agreeing to cover all the charges.

There have also been starts and stops with the regulation that impact providers and payments. In Texas, parts of the No Surprises Act were vacated by a federal judge due to some questions about the legality of the law’s designated arbitration process set up to resolve billing disputes between providers and insurers. Processing of payment determinations has recently resumed, with the Centers for Medicare & Medicaid Services giving arbitrators “the all clear to resume determinations on out-of-network payment disputes” and updated rules around the process.

Both of these situations highlight some critical gaps and loopholes that need to be addressed to protect both patients and providers, and help manage the healthcare affordability crisis in this country.

Here’s the bottom line: more issues in the No Surprises Act may rise to the surface, but there are positive patient-centric steps that can be implemented to ease the financial burden for patients and, at the same time, improve recovery of costs for providers:

  • Provide cost estimates for patients’ upcoming visits so they understand, upfront, what they can expect to pay.
  • Present patients with a consolidated view of all of their expected (and incurred) charges from individual service providers so patients can see everything they are responsible for in one place. This prevents confusion, eliminates surprises, and helps patients plan how to pay.
  • Provide convenient online payment options that streamline the process for your patients and finance team. Make it easy to track what payments have been made and what is still outstanding.
  • Offer flexible, self-service payment plans on both estimates and open balances to reduce the financial burden for patients. Tailor them to a patient’s financial circumstances to increase settlement. This can help offset the impact of any surprise balances a patient might be hit with.

Find out how Flywire can help transform the patient payment experience by personalizing the payment process at every step of their journey.