NSA FAQs: What Out-of-Network Providers Need to Know

Does the NSA impact me?

If you are an out-of-network provider (non-participating) with any or all commercial insurance plans, many of your claims will likely fall under a state-specific surprise billing law or the Federal No Surprises Act (NSA).  Generally, the NSA applies to all health plans (fully insured, self-insured, ERISA and non-ERISA) for emergency services performed at in or out of network facilities,  and non-emergency or scheduled surgeries performed at in-network facilities unless a valid notice and consent is obtained from the patient. Scheduled surgeries performed by an out-of-network (OON) provider at an out-of-network facility do not fall under the NSA. NSA does not apply to Medicare and Medicaid programs. State balance billing laws will apply first if the services are covered by a state specified law as defined under the NSA.

When is patient consent required?

Under the NSA rules, patients may receive notice  and  consent to waive the patient protections under the NSA for scheduled services at in-network facilities.  With valid notice and consent on file, providers are permitted to balance bill a patient according to the patient’s benefits for services rendered. Providers who submit a medical claim to a payor along with a valid notice and consent form executed by the patient, forfeit their right to dispute any payor payment under the NSA IDR process. An out-of-network provider may still schedule surgery for a patient at an in-network facility despite no notice and consent and the EOB issued for that claim should contain remark codes indicating the claim is subject to the NSA.

Can I obtain consent to balance bill ancillary services?

No, under the No Surprises Act, ancillary services, including services performed by assistant surgeons and services when there are no in-network providers available at the facility are always subject to balance billing prohibitions. The notice and consent exception does not apply to ancillary services.

What services should be included in a good faith estimate (GFE)?

Under the NSA rules, a self-pay or uninsured patient may request a good faith estimate (GFE).  A GFE should include items or services reasonably expected to be furnished to the patient by both the primary and co-provider.  The provider who receives the initial request for a GFE from a patient is designated as the convening provider and is responsible for preparing the GFE for all services being performed on behalf of the providers.  HHS has recognized that it may take some coordination between the primary and co-providers and in January 2023 delayed enforcement discretion of the GFE convening coordination provision. 

How does the NSA impact practices’ billing processes?

Many payors have yet to implement the appropriate measures to accurately identify and process claims that are subject to the NSA. Thus, remark codes may or may not be accurate.  Additionally, the remittance advice remark codes related to the NSA that were effective March 1, are not being utilized by the payors. Practices need to understand how to challenge underpayments properly and effectively under the strict set of time-sensitive NSA regulations.

What is the Payor-Provider dispute resolution process?

Under the NSA providers have a direct course of action to challenge payors under reimbursements through baseball style arbitration known as the independent dispute resolution (IDR) process. Providers have a 30-calendar day window from the receipt of an initial payment or notice of denial of payment to initiate the open negotiation period. If the provider and payor cannot reach an agreement by the end of the 30-day open negotiation period, the provider may initiate the IDR process.

How does NSA impact patients’ cost sharing obligations?

Under NSA, out-of-network providers are advised to collect only the cost sharing amount that would be collected if the patient was being cared for by an in-network provider. Any out-of-network healthcare cost subject to the NSA will be applied to a patient’s in-network deductible and out-of-pocket maximum.

Are state balance billing laws still applicable?

According to the Commonwealth Fund, 33 states have some form of legislation that bans surprise billing for certain types of services. The NSA is applicable only where state law does not apply. However, when applicable, state surprise billing laws take precedent over the NSA.  In some cases, a claim may be bifurcated with a portion falling under a state-specific surprise billing law and a portion under the NSA.

What is the median in-network rate? 

The median in-network rate, also known as the qualifying payment amount (QPA) is the basis for determining individual patient cost sharing for items and services covered by the balance billing protections under the NSA. The QPA is also one of the factors that certified IDR entities may consider when making arbitration award determinations for payment disputes between out-of-network providers and payors. 

CH Revenue Management, LLC is a one-of-a-kind billing and revenue cycle management company that offers a single source solution or ala carte services to out-of-network surgical practices.  If your practice is operating business as usual, and you are noticing a substantive decline in revenue since the NSA became effective, please contact us today for a free consultation – you will be glad you did. 

© 2023 CH Revenue Management Solutions, LLP

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