No Surprises Act Plus Direct Primary Care: A Better Healthcare Experience in ABQ

Before we try to understand a life-changing law that basically affects every insured or uninsured American citizen, let us first discuss in summary a major mistake with our healthcare system – surprise medical bills.

The Healthcare System Problem in a Nutshell

Both patients and healthcare providers have become outright victims of this broken system. When a corporate health system starts to charge more for the same services offered, it jumpstarts a spiraling abyss of consequences that gets worse as time goes by.

Patients bear the brunt of a flawed system. The burden of waiting for weeks for a doctor’s appointment is followed by another burden of waiting for minutes to hours in the waiting room. Entry to the clinic does not guarantee a productive visit because, like patient A, patient B is waiting outside which imposes a huge pressure on the healthcare provider to speed up his electronic medical records and everything. Follow-up questions will have to wait for the next follow-up visit and the cycle repeats itself.

Even with great insurance, surprise medical bills loom over every patient because of the specificity of getting services limited only within the “network”. What happens during emergencies remains to be seen – and it is during these times of uncertainty and anxiety that patients are forced to make decisions without thinking twice about them. 

With these in mind, quality compassionate empathetic healthcare becomes more expensive. Average clinic visits last for only 12 minutes – add in a cranky healthcare provider plus a weary patient in the picture, and the whole clinic visit becomes a disaster rather than establishing a pleasant and productive clinic visit.
Studies have shown that limited patient interaction is one of the strongest factors influencing the clinician burnout epidemic. In effect, most clinicians practice medicine because of their innate ability and yearning to help people. Limiting this interaction fuels dissatisfaction not just on the patient’s end but on the healthcare provider’s end as well.

Surprise Medical Bills

Unexpected bills can drain the life of any individual. But realize how much damage it can caus if it’s a medical bill draining what is left of a patient suffering from a chronic illness.

Surprise medical bills are unexpected medical bills that happen when one is given treatment outside the specific network or their medical plan. The element of surprise sets in when the patient has no idea that the healthcare provider or the service is not within the specified plan until the final medical bill is given. It is otherwise referred to as “balance billing”.

Without a bill safeguarding patients against surprise medical bills, insurance companies will continue to fool Americans into believing they have good health insurance. And that their insurance is enough to cover everything just in case something happens. After all, that is what insurance is for, right? You give up a small amount of money for the security of having someone to cover up for you in case something catastrophic occurs.

Getting to Know the No Surprises Act

Fret no more – one can finally be independent of the burden of surprise medical bills! Finally, a law that demands to prioritize patients over profits is now in effect and has been since January 01, 2022. This protects patients from the most common types of surprise medical bills. Here are the fast facts about the No Surprises Act:

1. Surprise bills for most emergency services are no longer allowed, even if they are obtained out of your insurance network and without prior approval.

2. Cost-sharing in the form of payments or out-of-network coinsurance is no longer allowed for most emergency and some non-emergency services.

3. Charging out-of-network dues and balance bills for certain additional services furnished by out-of-network providers as part of a patient’s visit to an in-network facility is no longer allowed. These extra surprise billings usually happen for services under anesthesiology or radiology.

4. Healthcare providers and facilities are now required to give their clients an easy-to-understand notice. The notice is expected to elaborate on applicable billing protections, including which person to contact regarding concerns about possible violations committed by the provider. 

5.  Patient consent is now a requirement prior to waiving billing protections.

6. The estimate of a medical bill given to a patient who does not have any insurance should be truthful and done in good faith (thus the term “good faith estimate”). If final charges are at least 400 USD than the given estimate, the patient has the right to dispute the claim within 120 days from receiving the bill.

7. The good faith estimate includes the charges for the following:

• The primary product/item/service; and
• Other secondary services or items that are included in the process of obtaining the primary product/ item/service

8. Your healthcare provider should give you your good faith estimate after you schedule your appointment. If requested for an appointment 3 business days before the date you are supposed to get the item or service, your healthcare provider is obliged to give you your good faith estimate no later than 1 business day after scheduling. If you requested an appointment 10 business days prior, your healthcare provider is obliged to hand over your good faith estimate no later than 3 business days after scheduling.

9. Some good faith estimates for surgical procedures may not be all-inclusive, as some other procedures may be scheduled separately. For example, a good faith estimate for a surgery done by an orthopedic surgeon will be separate from the good faith estimate for physical therapy that commences after the surgical procedure. 

No Surprises Act and the Direct Primary Care Model – A Promising Work in Progress

Although the bill, No Surprises Act, has already been in effect since January 01, 2022, it remains to be seen how it will affect both patients and healthcare providers in the long run. 

However, this bill coupled with having a direct primary healthcare provider seems to be a promising work in progress. 

The No Surprises Act takes care of all the excess baggage that might come in when out-of-network referrals happen. 

And the direct primary care provider solves the rest. This is because the direct primary care model answers flaws related to health provider accessibility, productive healthcare provider and patient interactions, healthcare provider burnout, and over-coverage done by insurance companies. 

The patient enjoys immediate, high quality and comprehensive health services for an affordable fee (otherwise known as the membership fee). Worth noting: telemedicine has gone a long way in helping patients maximize their direct primary care membership further. For example - mothers no longer have to endure long waiting room visits just to get a remedy for a child who just had a fever. As a result, everything becomes timely – the immediate remedy needed, health teachings, laboratory requests (if needed), and prescription.

Happy patients make happy clinicians as well! The healthcare provider enjoys the bliss of having continuity of care towards patients under her services, with no institutions, no insurance, and no middlemen to add to the already existing problems related to the patient’s health and wellbeing.

With the No Surprises Act and direct primary care model, we get to have a promising future in healthcare. Schedule an appointment with us to get to know more about the best direct primary care provider in ABQ!