With the January 1st, 2022 official enactment of the No Surprises Act (NSA) now prohibiting surprise patient bills, it comes as no surprise that healthcare providers across the country have since been evaluating the potential impact on their organizations.
"The No Surprises Act isn’t good news for providers who balance bill; they will need to alter their business practices and face a loss of income (for some, the loss will be significant). Insurance companies are also at risk under this new federal law; if their insured beneficiary received medical care- shouldn’t they have to pay for it- at least in part?" - Sarah Freymann Fontenot, BSN, JD, CSP
There are many factors to consider from the provider side. Given the new regulations, what should providers be most focused on today?
"Providers should be looking now at the current No Surprises Act IDR Rules; there will be very little time to get in compliance if these challenges fail (Congress set a one-year timeline for implementing the No Surprises Act for January 1, 2022). The impact of the No Surprises Act will vary significantly depending on your field of practice and your business patterns." - Sarah Freymann Fontenot, BSN, JD, CSP
The Independent Dispute Resolution (IDR) process for reimbursement disputes outline an initial payment of an undefined amount subject to the NSA that health plans and issuers will directly reimburse for out-of-network services to the facilities/providers, and which must be made within a specific timeframe – 30 days after the claim submission to be exact. The provider can either accept the initial payment or dispute the total offered amount through the IDR process within an open negotiation period. That open negotiation period allows for the dispute to be presented before a third-party arbiter if a settlement cannot be reached between both parties. Each side must submit a final offer and then the arbiter will select which of the two offers to award, after also first considering various factors like:
- Level of training from the provider’s side
- Market share of both the health plan and provider
- Good-faith efforts shown by each party
- Provider scope of services, cases, and teaching status
- Acuity of provided care
Given the above, and that after arbitration, it will fall to the losing party to pay the full cost of the awarded IDR,
"It now appears that insurers scored the win in the final rule-making process, and providers are calling “Foul” – both physicians and hospitals. Two pending suits challenge the prominence of “regional benchmarks” in the IDR process (one lawsuit led by the Texas Medical Association (TMA) and the other by the Association of Air Medical Services (AAMS)). The legal challenges bring forth important questions, but ultimately the court may find that the No Surprises Act is sufficiently ambiguous to allow for different weighing of factors in resolving billing disputes." - Sarah Freymann Fontenot, BSN, JD, CSP
Read more on the latest about Who Loses Under the No Surprises Act by visiting Sarah’s blog Fontenotes.
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