COVER STORY


Impact on Patients and ASCs Surprise medical bills are more com- monly associated with emergency and urgent care, says Andrew Weiss, CASC, administrator of Summit Sur- gical Center in Voorhees, New Jersey. In these instances, patients have less time—and thus control—to verify and arrange for in-network care. Yet, even with the non-urgent nature of ambula- tory surgery, surprise medical bills can accompany a procedure. “These bills are likely to occur with an ancillary provider rather than the ASC or surgeon,” Weiss says. "Pathol- ogy is a good example. A patient goes to an in-network ASC, sees an in-net- work surgeon but does not know that the center uses what turns out to be an out-of-network laboratory.”


Anesthesia providers are another


common example, Blaney says. “Anesthesiologists and nurse anesthe- tists are in high demand and have sig- nificant negotiating power with insur- ance companies, so it is not unusual for anesthesia providers to step out of network. Patients may confirm that the ASC and their surgeon are in net- work, but they are likely not going to ask about anesthesia or other ancillary service providers.” While ASCs might not typically be


the source for surprise medical bills, patients might still direct their ire about receiving such bills at surgery centers, Wilkins says. “Since a patient is generally communicating about sur- gery with their surgeon and the ASC, there is an expectation that they will be looking out for the patient's best inter- ests, both clinically and financially.” Upset patients


might take their


displeasure about surprise medical bills to social media, review websites and the media. Blaney says patients are increasingly bringing these bills to their employer's human resources departments for assistance, which can bring additional attention to the bills


New Law Takes Aim at Surprise Medical Bills


In late December, then President Trump signed the Consolidated Appropriations Act, 2021. Among its provisions: limiting the practice of balance billing patients, which leads to what is commonly referred to as “surprise medical bills.”


Under this bill, patients will be required to pay only the in-network cost-sharing amount for many types of out-of-network care provided at facilities that are in their health plan's network. A notice and consent process will make sure that patients can opt for out-of-network care. Providers will be required to post information about the new balance billing requirements and practices and will be subject to penalties for violations.


When reimbursement disputes between a provider and plan arise, they will be settled through a structured process involving open negotiations between the parties and arbitration. The bill requires plans to maintain price comparison tools on their websites so that policyholders can research their cost-sharing responsibility. This provision of the legislation also includes other obligations for providers and plans. The US Department of Health and Human Services secretary will issue final rules to guide implementation and provide clarity for providers and plans prior to the limitations going into effect in 2022.


and potentially sour employers on working with ASCs. “Considering the national scrutiny on these practices, physicians and pri- vate equity firms looking to invest in ASCs may also be dissuaded by reports of surprise medical bills because of the reputational harm they can cause,” Blaney says.


Weiss adds, “You are not going to survive in business if you are associ- ated with a model that routinely leads to surprise bills.”


ASCs also have the potential to run afoul of state laws if they are not care- ful, Weiss says. The Commonwealth Fund states that as of November 2020, more than 30 states had enacted laws


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