The No Surprises Act Summary
The sweeping changes incorporated into the No Surprises Act (NSA) have become effective JAN 01, 2022.
Key impacts effective JAN 01, 2022, include:
BALANCE BILLING FOR CERTAIN OUT-OF-NETWORK SERVICES
• Patients protected from balance billing for emergency and certain ancillary services
• Patients protected from out-of-network bills when they are treated at in-network facilities
• A federal Independent Dispute Resolution process (IDR) is available for providers and payers who are unable to successfully negotiate an out-of-network payment for services
PRICE TRANSPARENCY FOR SCHEDULE CARE
• In most cases, scheduled care for insured patients must include a good faith estimate (GFE) of all expected charges, including those of other providers normally involved in the scheduled service or procedure
• Uninsured (or Self Pay) patients who request or schedule care are to be provided a GFE of expected charges, including those of other providers normally involved in the scheduled service or procedure
• Uninsured (or Self Pay) patients have access to a federal Patient-Provider dispute resolution (PPDR) process when charges exceed the GFE by more than $400
A key element related to price transparency has been delayed so providers and payers can establish systems and processes to exchange necessary data:
• Scheduled care for insured patients will include a GFE of the charges and the patient’s insurance carrier must provide an Advanced Explanation of Benefits (AEOB) indicating the patient’s cost sharing responsibilities.
Independent Dispute Resolution (IDR) Process
• A timeline is established for payer response to providers once a claim is submitted
• A timeline is established for negotiations between out-of-network providers and payers
• If the IDR process is initiated, both parties must pay the non-refundable administrative fees ($50 each for 2022)
• Both parties must submit their final offer and the selected IDR entity fees ($200-$500 for a single claim or $268-$670 for batched claims, unless posted otherwise)
• If no agreement is reached prior to the IDR entity’s decision, the IDR entity is instructed to select the offer closest to the payer’s Qualifying Payment Amount (QPA) unless “credible information…demonstrates that the QPA is materially different from the appropriate out-of-network rate. (86 FR 55995).
• The non-prevailing party forfeits its IDR entity fees; the prevailing party is refunded its IDR entity fees
• The QPA is defined as the median in-network rate for a service
- For the same or similar specialty
- Same geographic region
- Same insurance market
It is possible that the No Surprises Act standards and procedures will be modified further as implementation proceeds (and federal courts consider legal challenges to these regulations).
As will be clear from the above, medical billing can sometimes become a nightmare. Fortunately, there is help: Ultimate Billing is a billing and revenue cycle management company that helps healthcare organizations such as rural hospitals maximize their collections and revenue.
If you’re ready to maximize collections and revenue for your organization, set up a quick consultation with our team today.