The No Surprises Act (NSA) and the continuing adoption by States of laws prohibiting balance billing for certain services has changed the Revenue Cycle Management landscape for the out-of-network provider. Historically authorizations, billing, and account receivable management fell into a relatively clear pathway in dealing with payors, although not equally balanced.  Under the NSA and with some States having laws prohibiting balance billing for certain services, while other States do not, out-of-network billing and reimbursement poses additional challenges and requires new processes as part of revenue cycle management. Since implementation of the NSA in January 2022, we have seen many provider practices failing to adjust to this new reality.  Deadlines are being missed, required documentation is not being submitted and claim follow-up is being processed with an incorrect party. Providers are seeing reimbursements down with little understanding of why – except that the “No Surprises Act” has been implemented and changed everything. It does not need to be this way with the proper revenue cycle management as out-of-network providers can prosper under the No Surprises Act, in some cases, with reimbursements for the out-of-network provider being more favorable than reimbursement of claims administered by insurance companies under patient benefit plans.  REVENUE CYCLE MANAGEMENT ADJUSTMENTS FOR THE OON PROVIDER First, while the authorization process has not yet changed, the questions asked during this process should be expanded.  A few examples are — Is the plan fully insured or self-insured? If fully insured, in which State is the policy issued? Are there in-network providers at the facility who can provide these services? If so, please provide a list of the physician names.  These and other questions will help in identifying a claim pathway once payment is received.  Knowing this pathway is critical because a failure to timely respond can eliminate opportunities for additional reimbursement.  For instance, for emergency services claims under self-insured plans that are subject to the NSA, a provider has thirty business days to initiate a negotiation with the payor from receipt of initial payment.  The remittance advice should set forth where to initiate this process and the phone number to call. We have seen providers miss these deadlines and payors strictly enforcing this thirty-business day period. Adding processes at this time to revenue cycle management is critical for success. NOTICE AND CONSENT MAY APPLY For certain services under the NSA, a patient can elect to waive the protections of the NSA prior to the services being rendered through the notice and consent process.  Payors are currently inconsistent with the application of the NSA notice and consent process.  Some payors recognize the notice and consent by issuing remittance advice without the NSA remark codes.  Others are adding the NSA remark code to remittance advices even though a valid notice and consent has been submitted as a part of the claim file.  Still, other payors are not even placing the NSA remark codes on the remittance advice where there is no notice and consent submitted with the claim (or for that matter, where services were for emergency care).  Knowing which services and when to request the notice and consent from the patient needs to be addressed as part of the patient intake process. Until there is uniformity by all payors in the application of the notice and consent process, providers need to know how its payor mix administers claims under the No Surprises Act.  NSA ARBITRATION AND STATE LAW IDR CAN BE EFFECTIVE TOOL FOR OON PROVIDER The NSA and certain State laws have established the IDR/Arbitration process using a baseball style type of arbitration.  While there are differences on timing and how each party submits an offer, the process is similar in requiring the arbitrator to select one of the two offers. Prior to this baseball style arbitration being available, parties are encouraged to engage in negotiations to resolve payment disputes. Under the NSA, we are seeing many payors failing to negotiate and others engaging in negotiations that are far from being called good faith.  While the guidelines state that payors and providers should negotiate for a 30-business day period, many payors are ignoring these guidelines.  Instead, payors continue to adhere to QPA for reimbursements during open negotiations and submit the QPA as the “offer” in arbitration.  In several instances, IDR entities have awarded providers with favorable outcomes in light of payors failure to negotiate and/or offer meaningful reimbursement for complex surgeries. With proper planning, documentation and arbitration submissions, providers can be successful and overcome the low QPA amounts. For now, billing companies continue to scramble under this complex set of NSA rules. Some are completely overburdened by the detailed requirements under the NSA, some are completely overwhelmed and unable to adjust and others lack awareness of the NSA rules to even execute properly. Under all these circumstances, out-of-network providers are losing out on additional reimbursement opportunities.  The NSA and State law requirements are becoming increasingly complex and require detailed processes to be successful. Interpreting these rules is challenging and billers need to understand the thousands of pages of rules and guidelines to be successful.  Out-of-network providers need to review their practices and processes so that claim payments can be timely challenged for additional reimbursements under the proper claim pathway, whether that be the NSA, state law and/or the administrative appeal process. © 2023 CH Revenue Management Solutions, LLP

One of the single most essential factors to maximize medical out-of-network claim reimbursement is accurate medical billing and coding. Even the slightest mistake can result in a delay or denial of a claim as payor automated processing systems are set up to deny claims for billing and coding errors. A successful coding and billing process should yield a nearly 100% claim acceptance rate. Practices also need to understand how a billing department/company has established its process for claim follow up and the timelines implemented for these processes.  Absent a detailed process, claims can become ‘lost’ in the billing/collection cycle and time-out for reimbursement. 6 Billing, Coding and Practice Management Tips for Increasing Provider Revenue: Find root causes. Evaluate and correct the root cause of each claim rejection and denial and apply best practices to have the claim corrected and resubmitted within 24 hours, if feasible. A rejected claim has not been established as a timely filed claim and if not quickly resubmitted with necessary corrections, could time out as a timely filed claim. Employ a thorough patient eligibility and verification of benefits process. Setting up the claim to pay correctly begins with a detailed verification of benefits process and helps to avoid any errors in the collection of patients’ co-payment amounts. Practices should be extra vigilant in making sure patients are not being overcharged, particularly now as out-of-network claims will sometimes process according to a state-specific or federal surprise billing law. Know the Codes. Every specialty or surgical practice has reoccurring medical codes that are routinely used for commonly administered procedures.  Knowing how to apply the proper modifier and any multiple procedure reductions (MPR) is equally as important to ensure the claim processes in a timely manner. The billing team and practice administrators should be well versed in the proper use of these codes/modifiers, ensure that operative reports support the codes being billed and should have a mechanism in place to track payment data by each CPT code and carrier. Under the No Surprises Act, this information is increasingly more important for pursuing and resolving disputed payment amounts between providers and payors. Adapt Coding Requirements Accordingly. For many surgical specialists, especially those performing advanced procedures, coding can be challenging as “recognized” coding may vary by insurance companies. As an example, certain procedures allow for an assistant surgeon while other similar procedures may not. Requirements for authorization for certain codes can also be dictated specifically by the policy or health benefit. Maintain accurate documentation. For pre-service authorizations and any assertions made by the payor pertaining to how the claim will be paid (ie UCR; multiple of Medicare, etc.), copious notes should be captured and recorded, as permitted by applicable law. Appeal under-reimbursed or denied claims. Any facts documented can and should be used to consistently and persistently to appeal denied and underpaid claims. Dedicated resources should be allocated within a practice (or outsourced to specialists) to implement a rigorous and effective appeal process. For claims not subject to a state-specific or federal surprise billing laws, payors generally allow 180 days to file an initial claim payment dispute, but time periods can vary by payor and type of plan. Also, It is important to note that all claims should not be treated equal and each claim should be evaluated by applying a specific methodology for determining the True Maximum Value of a Claim. Call Today To Discuss Our 360 Revenue Management Solution Maximizing practice revenue begins with preservice, coding and billing. As the healthcare reimbursement landscape evolves, new regulations are enacted, and payor tactics to minimize payments persist, practices need a strong bench with deep knowledge of the out-of-network revenue cycle management and a clear understanding of the factors that impact revenue throughout the process. Moreover, for certain underpaid or denied claims where payment is still disputed after the billing appeal process, the quest for payment should continue as warranted. CH Revenue Management Solutions and its affiliate Cohen Howard, LLP are collectively the only market solution capable of handling out-of-network provider claims from start to finish. Having billing, coding, insurance, regulatory and legal expertise leveraged, and services managed across the RCM and beyond, provides a solution that clients are seeking.  With our service solutions, clients are saving countless hours and resources handling business administration and revenue management functions. Instead, they are focusing their time on patient care while our team provides the deep bench necessary to maximize revenue for their out-of-network practices. Call us today for a free consultation on how we can help your practice maximize revenue.

NEW YORK (Reuters) – Park Avenue plastic surgeon Dr. Douglas Senderoff usually performs tummy tucks and liposuction for well-heeled New Yorkers. But with his practice suspended because of the coronavirus crisis, Senderoff wants to help colleagues on the front lines of fighting the virus in the city’s hospitals, where healthcare workers are trying to keep up with a flood of new patients. He also has an office anesthesia machine that can be converted into a ventilator. There is a critical shortage of ventilators in the United States to treat people suffering the potentially deadly new flu-like virus, which can lead to breathing difficulties and pneumonia in severe cases. New York, the epicenter of the outbreak in the United States, is among many U.S. states scrambling to procure more ventilators as quickly as possible. “We’re sitting on the sidelines right now,” Senderoff said of himself and his fellow plastic surgeons. “But we’re a resource. We all have general surgery experience. We have ICU experience. There’s hundreds of us just sitting around, waiting for the call,” he said in an interview. Senderoff is among members of the American Society of Plastic Surgeons who have offered their equipment and registered for the medical reserve corps in their states. Reserve corps are volunteer health workers ready to respond to emergencies like that of the coronavirus. The plastic surgeons society has launched an online clearinghouse for equipment and supplies to hospitals in need. Since then, it has received over 150 offers to donate supplies and equipment, including for about 40 ventilators, according to Adam Ross, a spokesman for the group. Dr. Chris Craft, a plastic surgeon in Miami, said he is among those who answered the call from the society last Friday to contribute equipment. He said his office is filled with medical supplies because now is normally when people have cosmetic work done in preparation for the coming beach season. “This is the biggest season for us for cosmetic surgery,” Craft said. “We’ve stockpiled for that and that’s not going to happen, so we need to do our part to see if we can help those who are on the front lines for us.” The American Society of Plastic Surgeons has about 8,000 members in the United States, about a third of whom are active members in private practice. Reporting by Karen Freifeld, editing by Ross Colvin and Rosalba O’Brien https://www.reuters.com/article/us-health-coronavirus-usa-plasticsurgeon/no-more-tummy-tucks-us-plastic-surgeons-idled-by-coronavirus-offer-help-idUSKBN21C3O1