A Federal Guardianship for Patient Rights – USA

A Federal Guardianship for Patient Rights

Healthcare billing services cater to providers in managing their revenue cycles. They coordinate with the insurance companies for all in-network billings. However, what about the out-of-network patients? These patients get their surprise medical bills from their respective medical companies in the USA. Don’t you think such bills can be an unwanted burden for such patients? Anyhow, CMS has an effective solution for all such problems. It now protects the patient’s rights with the ‘No Surprise Act’.

Have you ever dealt with such surprise medical bills? For our learners, we are going to give a little but understandable introduction of;

Who may be considered ‘Out-of-Network patients’ in healthcare?

What are ‘Surprise Medical Billing Services’ for them?

And, how does the ‘No Surprise Act’ protect the patients from such unwanted surprises from healthcare billing services?

Let’s dig in!

‘Out-of-Network’ or ‘In-Network’ Terminologies



When you take medical assistance and treatment beyond your insurance plan or SBC.

In such cases, the attending provider doesn’t have an agreement with your insurance company-the payers.

When you get medical assistance and treatment as per your insurance plan’s benefit and coverage summary.

In such cases, you turn to those providers only who have an agreement with your insurance company.

Healthcare billing services have a streamlined RCM process for dealing with account receivables. However, health billing services follow relatively different policies to handle any out-of-network patient.

Surprise Medical Billing/ Balancing Bills

Getting the right medical care and assistance is the right of any patient. However, receiving payment for services rendered to a patient is the provider’s right. Usually, patients have different insurance plans and insurance companies clear the dues under SBC. Anyhow, this is in case of some emergencies or out-of-network visits, when payers refuse to pay the bills. In such situations, healthcare billing services present balancing billings or out-of-network billing. That’s how they ask patients to pay what is still due in their pocket.

This is another case when in an emergency visit, the insurance providers agree to pay some portion of the medical bill. So, healthcare billing services pass the leftover bill portion to you. And ask you to respond via effective AR management.

When does One get a Medical Surprise Bill?

Every insurance company usually gives four types of insurance plans. These are:

  1. Preferred Provider Organization (PPO)
  2. Point of Service (POS)
  3. Exclusive Provider Organization (EPO)
  4. Health Maintenance Organization (HMO)

Under these four plan types, it tends to cover all in-network, non-emergency, and emergency out-of-network visits.

  • All in-network patients can get medical care under all four insurance plan types. So, there is no loophole for healthcare billing services to process medical claims.
  • Some insurance companies provide out-of-network benefits in non-emergency situations for PPO and POS only. However, the EPO and HMO uncovered services, patients have to pay the entire cost for the episode of care they got.
  • As we know, emergencies are marked as any unwelcoming serious condition. Thus, a patient needs instant care from any nearby hospital or provider. Therefore, health insurance companies have slight flexibilities for such out-of-network emergency visits. Both EPO and HMO bear 100% expense of physician care services. On the other hand, PPO and POS share a portion of the medical bill (a few percent, less than 100%).

How Out-of-Network Patients React to Surprise Bills?

Usually, the provider listed under the patient’s insurance plan offers discounted rates. However, healthcare billing services charge non-discounted rates to out-of-network patients. These patients are usually unaware of such surprise bills. And we make them accountable for paying the bills, which creates a huge stress on them. Most of the time they are not on good financial terms. So they delay the bill payments as much as they can. This ultimately affects the providers as well.

Thanks to the ‘No Surprise Act’ by CMS

CMS has acted on the problems reported by surprise medical bills from healthcare billing services. Thus, the ‘No Surprise Act’ – the US federal law declares:

Both in-network and out-of-network medical professionals may provide services in the hospital. You may get a separate bill from out-of-network providers.

Even while your hospital may be in-network with your insurance, not all of the doctors who treat you there must also be.

Before making an appointment, check with your insurance company to see if the hospital and its physicians are covered under your plan.

Attention Here!

The No Surprises Act does not apply to those with Medicare Advantage, Medicaid, Indian Health Services, VA health care, or TRICARE insurance plans. These are government insurance systems that already have safeguards in place to reduce significant, unexpected costs.


Healthcare billing services have the role of billing and submitting claims. And then collect the billing amounts for the providers. However, their billing services for all in-network patients go very smoothly. They occasionally get hampered by the claim denials a little bit but healthcare billing services manage denials well. On the other side, we have surprise medical bills for out-of-network emergency visits or several scheduled services without prior patient consent. Thus, out-of-network patients may not expect to get such a balancing bill which can overburden them financially. Thus, the No Surprise Act provides patients with the required protection from such bills and secures their rights.

The function of healthcare billing services is to charge and submit claims. The billing funds are subsequently collected for the providers. Their billing processes, on the other hand, run quite smoothly for all in-network patients. They are occasionally impeded by claim denials, but healthcare billing firms manage denials efficiently. On the other hand, we have unexpected medical expenditures for out-of-network emergency visits or several planned procedures that were performed without prior patient approval. As a result, out-of-network patients may not anticipate to get such a hefty bill, which might financially burden them. As a result, the No Surprise Act protects patients against such costs and guarantees their rights.

No more unwelcoming surprises for out-of-network patients by healthcare billing services as CMS has implemented the ‘No Surprise Act’ for securing patients’ rights since January 2022.

Call us for more information

Alexa Grace

Cone Sleeves can help attract customers to your product. With eye-catching designs and branding, customers are more likely to choose your cones over competitors.

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