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.
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