Out-Of-Network Medical Billing & The New No Surprises Act: Time For A Check-Up On Your Billing Company

In late 2020, the No Surprises Act was enacted into law. The No Surprises Act changes the landscape for out-of-network medical billing as the NSA regulates virtually every patient claim that will present to your practice- including those for self pay and the uninsured. The law, together with the first two of many rules that have followed, contain over 1,000 pages of new requirements that will require an in-depth understanding by your medical biller in order to achieve maximum reimbursement for your practice. New, shortened timelines for claim handling require processes in place from the receipt of the initial payment or denial of a claim to ascertain the claim pathway. The intersect between State law and the NSA will need to be analyzed, knowing whether a claim is to be appealed, negotiated under the NSA or arbitrated under State law is critical for success. Having the proper paperwork signed in advance by patients and knowing the patient’s benefit plan terms and effectiveness are all part of the checklist needed with the NSA now taking effect during 2022.

Historically, out-of-network practices would check on authorization, including GAP exceptions, prior to rendering services, seek to negotiate claims both before and after submission of claims and then appeal denials and low reimbursements. While these practices will continue as part of the NSA, far more will now be required. Practices will need to provide certain notices to patients and in certain cases, obtain a patient’s consent for balance billing for out-of-network services. However, these patient consents will not always be effective in all circumstances, including where the services relate to post stabilization, where networks are inadequate or the services are provided by assistant surgeons. Dissecting these details and understanding the implications needs to be integrated into the out-of-network billing process.

Timely response to all claim communications must occur. The NSA has created a very tight set of timelines for challenging payor reimbursement. State law deadlines differ. This complexity is further enhanced as a part of a claim may fall under the NSA while another part of the claim may fall under State law or none at all. How your billing company handles these new requirements going forward needs to be addressed. Without a comprehensive program in place, a practice will suffer.

At CH Revenue Management Solutions, we have been battling in the trenches for several years against payors operating throughout the United States.  We understand the need for process, having challenged plans and payors for years through preservice authorization denials, appeal and other efforts. Our team has extensive understanding of how payors work and have successfully overcome delay and other tactics utilized by payors to derail out of network providers. We maintain an extensive database on payor out of network claim data, benefit plan documentation and written communications that provide leverage in negotiating claim resolution with payors and their third party repricing agencies. We have experts on staff who have devoted substantial time and effort to understand the No Surprises Act and the interrelation with State laws. When needed, we work with our network of attorneys, at our expense, to pursue action against payors and plans, including Cohen Howard, a nationally recognized law firm devoted to the  representation of the out-of-network practice.

Practices will need to review their billing processes and procedures as part of the implementation of the NSA. Should your practice need advise or be looking for a company with a keen understanding of revenue cycle management and medical billing for the out of network provider, contact us today for a free consultation.

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