HCM 3080 Module 12 Legislation Final Project Example

Ending the Surprise Bill: A Historical, Content and Ethical Analysis of the No Surprises Act and Its Compliance Demands at Riverbend Community Hospital

Student Name

B.S. in Healthcare Management, Thomas Edison State University

HCM-3080: Healthcare Legal and Ethical Considerations

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Month Day, Year

Ending the Surprise Bill: A Historical, Content and Ethical Analysis of the No Surprises Act and Its Compliance Demands at Riverbend Community Hospital

The HCM-3080 final project asks for a piece of legislation that directly affects health care to be analyzed historically and by content, for the ethical basis of the law to be explained, for its impact on a particular workplace to be evaluated, and for compliance recommendations that account for the roles of different providers and organizations. This paper analyzes the No Surprises Act, enacted in December 2020 as part of the Consolidated Appropriations Act, 2021, and in effect since January 2022, and applies it to Riverbend Community Hospital, an invented 180-bed hospital in southern New Jersey used throughout this course.

History: The Problem the Law Answered

A surprise bill occurs when a patient who has done what insurance requires, such as going to an in-network hospital, receives a bill from an out-of-network provider the patient did not choose, often an emergency physician, anesthesiologist or radiologist working at that hospital. The provider bills the patient for whatever the insurer did not pay of its full charge, a practice called balance billing. Research documented how common this had become. Garmon and Chartock (2017) estimated that in 2014, 20% of inpatient admissions that began in the emergency department and 14% of outpatient emergency visits likely led to a surprise bill. Sun et al. (2019), studying privately insured patients treated at in-network hospitals from 2010 to 2016, reported that out-of-network bills followed 32.3% of emergency visits at the start of the period and 42.8% by the end, and the share of inpatient admissions from 26.3% to 42.0%, with average potential patient liability rising sharply.

States moved first. New Jersey enacted its own out-of-network protections in 2018, and many other states passed laws as well, but state laws could not reach the self-funded employer plans through which many employers insure their workers, which are governed by federal law. Federal legislation was debated for several years, with disagreements between hospitals, physician groups and insurers mainly about how out-of-network payment amounts would be set. The final law protected patients first and created a dispute resolution process for the payment question.

Content: What the Law Requires

The law's central protections operate on providers and facilities as well as on health plans. For emergency services, an out-of-network provider or facility may not bill a covered patient more than the in-network cost-sharing amount (42 U.S.C. § 300gg-131). For non-emergency services provided by out-of-network providers at in-network facilities, the same balance billing ban applies unless the patient gives informed written consent after receiving notice, and that notice-and-consent option is not available for certain ancillary services, including emergency medicine, anesthesiology, pathology, radiology and services provided by hospitalists and assistant surgeons (42 U.S.C. § 300gg-132). For patients who are uninsured or choose not to use insurance, providers and facilities must hand over a good faith estimate of what scheduled care will cost (42 U.S.C. § 300gg-136). Disagreements between plans and out-of-network providers about payment amounts are settled first by negotiation and then, if that fails, by an independent arbiter, keeping the patient out of the dispute.

The Law's Ethical Basis

The law rests on several ethical principles. Justice requires that patients not bear costs they had no fair opportunity to avoid; a patient unconscious in an ambulance cannot choose an in-network emergency physician. Nonmaleficence applies to financial harm, which can cause patients to delay care or fall into debt. Respect for autonomy underlies the notice-and-consent provisions and the good faith estimate, which give patients information to make choices when choice is real, while the exclusion of ancillary services recognizes that patients do not choose their anesthesiologist or radiologist in any meaningful sense. The law also reflects a view of fairness among the parties: payment disputes are real, but they belong between insurers and providers, not on the patient's bill.

Impact on the Workplace

At Riverbend, the law affected four groups. The emergency department's contracted physician group, previously out of network with two large insurers, could no longer balance bill those patients and became subject to dispute resolution for payment, which pushed the group to negotiate network contracts. The anesthesia, radiology and hospitalist groups lost the option of seeking patient consent to out-of-network billing. Scheduling and registration staff took on the good faith estimate process for self-pay patients, which required new workflows and training. The revenue cycle department had to track disputes and make sure no patient statement included amounts beyond in-network cost sharing for protected services. The hospital also became responsible for posting required notices about patients' protections.

Compliance Recommendations

Compliance depends on coordination among parties who do not all work for the hospital. First, every contract with a physician group practicing at Riverbend should require compliance with the law, cooperation with audits and indemnification for violations. Second, the billing system should flag claims for emergency and ancillary services from out-of-network clinicians and block patient statements above in-network cost sharing, with a quarterly audit of a sample of statements. Third, registration staff should be trained to identify self-pay patients and issue good faith estimates within the required timelines, with a simple escalation path when charges are uncertain. Fourth, a single compliance owner, the director of revenue integrity, should track dispute resolution deadlines, patient complaints and regulatory updates, since federal rules implementing the law have changed through litigation and new guidance. Fifth, patient-facing staff should be able to explain the protections in plain language, so that patients know they should not pay a bill that the law forbids.

Conclusion

The No Surprises Act grew from evidence that patients were being billed for care they could not choose. It answers that problem with protections grounded in justice, nonmaleficence and respect for autonomy, and it places the burden of payment disputes on the parties able to negotiate them. For a hospital, compliance is not only a billing task but a matter of coordinating physicians, staff and systems so that the law's promise reaches each patient.

References

Garmon, C., & Chartock, B. (2017). One in five inpatient emergency department cases may lead to surprise bills. Health Affairs, 36(1), 177-181. https://doi.org/10.1377/hlthaff.2016.0970

Sun, E. C., Mello, M. M., Moshfegh, J., & Baker, L. C. (2019). Assessment of out-of-network billing for privately insured patients receiving care in in-network hospitals. JAMA Internal Medicine, 179(11), 1543-1550. https://doi.org/10.1001/jamainternmed.2019.3451

42 U.S.C. § 300gg-131 (Supp. IV 2022). Balance billing in cases of emergency services. https://www.law.cornell.edu/uscode/text/42/300gg-131

42 U.S.C. § 300gg-132 (Supp. IV 2022). Balance billing in cases of non-emergency services performed by nonparticipating providers at certain participating facilities. https://www.law.cornell.edu/uscode/text/42/300gg-132

42 U.S.C. § 300gg-136 (Supp. IV 2022). Provision of good faith estimate of expected charges. https://www.law.cornell.edu/uscode/text/42/300gg-136