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3 Ways a New Federal Law Could Change U.S. Hospitals

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What You Need to Know

  • EMTALA is the federal law that has governed how hospitals deliver emergency care.
  • The new federal No Surprises Act uses an entirely different definition of what an emergency is.
  • A health tech expert says the new law may lead to insurers and hospitals signing new, reimbursement-only agreements.

The new federal No Surprises Act (NSA) could force U.S. hospitals to play more gently with insurers, and possibly increase the amount of care they provide for uninsured patients.

The act has many pieces. One well-known part could help any insured clients you have who get emergency care from hospitals outside the insurers’ provider networks.

Hospitals that are “part of a plan’s provider network” have signed agreements that may cover everything from what they charge for liver transplants to how quickly plans must pay claims.

Today, in many states, an out-of-network hospital can bill your client as much as they like for emergency care. A health insurer may be able to pay what it defines as “usual, customary and reasonable” amounts for the care and leave your client to fight with the hospital over the balance.

The NSA calls for the hospitals and insurers to eliminate “balancing billing” of patients for emergency care. Hospitals and insurers will have to wrestle over an eligible patient’s balance with each other, with help from mediators.

Federal agencies posted draft NSA regulations in early July.

Matthew Albright, chief legislative affairs officer at Zelis, a health care payment technology company, is one of the many health policy watchers trying to figure out what the new emergency care reimbursement rules will really mean.

Before Albright went to work for Zelis, he spent about four years at the Centers for Medicare & Medicaid Services, one of the agencies in charge of implementing the NSA emergency care reimbursement provisions.

Here are five things he’s seeing, drawn from answers to a recent email interview.

1. The new NSA definitions of “emergency services,” “emergency medical condition” and “to stabilize” a patient could affect how hospitals define “emergency services” in other situations.

The federal Emergency Medical Treatment and Active Labor Act of 1986 (EMTALA) requires hospitals to stabilize all patients who come in facing medical emergencies, regardless of those patients’ ability to pay for medical care.

EMTALA is one reason U.S. hospitals face large uncompensated care totals.

The NSA sets new, broader definitions of the same kinds of emergency-related terms used in connection with EMTALA.

Albright says the NSA emergency care language could eventually affect how EMTALA works, too.

State emergency care laws will take precedence over the NSA rules, but when the NSA rules apply, they will prohibit payers from denying payment in an emergency based on the ultimate diagnosis, Albright says.

Under the NSA rules, “the claim must be considered an emergency based on the patient’s presenting symptoms,” Albright says.

The new, broader NSA definition of emergency could increase the confusion and contention over the scope of emergency care, he predicts.

2. Hospitals may want to have deals with more insurers.

Today, some hospitals with large populations of patients with Medicaid and Medicare avoid joining commercial provider networks. When those hospitals do treat patients with commercial coverage, they charge the commercial insurers very high prices for out-of-network care.

When the NSA emergency care rules take effect, “we will likely see a substantial increase in the use of non-network reimbursement agreements. These are agreements that providers sign with payers or payment vendors on reimbursements only, instead of comprehensive ‘in network’ contracts,” Albright says.

3. The NSA could revive reimbursement-only agreement programs.

Some hospitals and insurers already use reimbursement-only agreements.

The NSA now makes those agreements a tool that hospitals can use to avoid facing expensive, time-consuming negotiation or arbitration, Albright says.

“The payer and the provider can negotiate these agreements according to their own timelines,” he adds. Otherwise, he says, the payer and provider might have to face deadlines set by state and federal agencies.

(Image: Adobe Stock)