When Congress passed the No Surprises Act (NSA) in December, 2021, its goal was to eliminate the unexpected (and often huge) medical bills that patients received for both emergency visits and from out-of-network providers involved in planned in-network procedures. The burden of the surprise bills was often extraordinary — driving legislators to take patients out of the middle of the billing process for those specific situations. The No Surprises Act (NSA) and its implementing regulations outline the way in which payers and providers must approach emergency and certain out-of-network billing…but that doesn’t mean there was instant relief for any of the parties involved.
This was a sweeping change, particularly for payers and providers, and there’s no way they could get up to speed on every nuance of the new rules by the time they were enforced in 2022. The result?
With the Rise of AI, What IP Disputes in Healthcare Are Likely to Emerge?
Munck Wilson Mandala Partner Greg Howison shared his perspective on some of the legal ramifications around AI, IP, connected devices and the data they generate, in response to emailed questions.
- Patients are still receiving some surprise bills
- Providers and payers continue to strive for compliance with the complex reimbursement process
Let’s look at what patients should do if a surprise bill comes their way, and how payers and providers can prepare their internal systems to adjust to the new rules and ultimately reduce the cost of medical claims.
Patients: don’t pay the surprise bill
If a patient receives a provider’s bill for an emergency visit or an out-of-network service that was part of a scheduled in-network experience, they shouldn’t panic. The patient is no longer responsible for paying that bill! Instead, the patient should contact their payer who will resolve the reimbursement with the provider.
A Personalized Approach to Medication Nonadherence
At the Abarca Forward conference earlier this year, George Van Antwerp, managing director at Deloitte, discussed how social determinants of health and a personalized member experience can improve medication adherence and health outcomes.
Patients should also remember that all medical bills are not “surprise” bills. When patients choose an out-of-network physician or other specialist for a scheduled appointment, or an out-of-network facility for a scheduled procedure, they’re deliberately seeking care outside their network. Therefore, they’re subject to higher co-pays or co-insurance, and also may receive a “balance bill” for the difference between the provider or facility’s charges and the amount covered by the health plan. While this bill may be a surprise to some patients, it’s not a surprise bill under the No Surprises Act. And when the advanced estimate and consent requirements of the No Surprises Act are fully defined and implemented, balance bills also shouldn’t take the patient by surprise.
Another note to patients and their healthcare providers: they’re covered by the NSA during their health plan year. So, if their plan takes effect September 1st, that’s when the new rule applies to them, and not on January 1st when the law took effect.
Changes galore for payers and providers
Under the No Surprises Act, payers and medical providers have three possible steps to resolve medical bills:
- The provider bills the payer, the payer pays the bill and the provider is satisfied with the reimbursement – end of claim.
- If either party disagrees with the reimbursement amount, the provider and payer may take as long as 30 business days to negotiate a new amount. If that negotiation is successful, the reimbursement is adjusted and the claim is closed.
- If the payer and provider are unable to agree on a final amount, either can initiate an independent dispute resolution (IDR) process where a certified arbiter reviews their proposals and selects one to be the final out-of-network reimbursement rate.
As a result, reimbursement for applicable unexpected out-of-network provider services has become a bit of a chess game for both providers and payers. How much should the payer reimburse, hoping it will be accepted by the provider so that both parties avoid negotiation or arbitration?
Then there are unexpected rules within the No Surprises Act, such as wrapping the federal law around the 22 states which have their own rules against surprise billing for patients with fully insured health plans. Therefore, for insured plans, protections may be a mix of federal and state, only the state, or only the federal if the state has not been deemed a “specified state law.” Self-insured plans are protected just by the federal NSA.
Another twist in the NSA is the Qualifying Payment Amount (QPA), a measurement of the median contracted rates used to determine the likely fair reimbursement for a claim. By basing patient cost share on QPA, patients are held harmless from any additional payment the health plan makes through the post-payment negotiation and IDR processes. But most payer adjudication systems calculate plan and patient cost sharing using the amount the plan allows for the claim, so they weren’t prepared to support this process of determining cost sharing based on a different amount.
Compliance requires new technology and more data
How can payers and providers best cope with the No Surprises Act regulations? Most payers have been negotiating and reimbursing medical claims – and sometimes even arbitrating them — for years, and have the processes in place to do so. However, the new rules are making it necessary for them to tweak those systems, anywhere from a little to a lot. Their technologies must be able to identify a surprise bill, and take into account the QPA as well as the federal/state implications of the NSA. And providers need to understand those rules in order to make the right decision to accept or reject the initial surprise bill payment.
This is where an abundance of data, and thorough predictive and prescriptive analysis of that data, will contribute to the outcome each party seeks if the initial payment is challenged.
For example, the provider charges more for a surgery because the patient was extremely ill, they were treated in a more costly teaching hospital, and/or the surgeon is the only one practicing in that market. But the payer’s data shows the patient was not in severe condition, that the surgery could have been performed successfully by a number of other surgeons, and that the QPA would already reflect the higher costs of the hospital. By collecting the right data, and using analytics to understand it, each side can better make its case during the negotiation or the IDR.
Stand by for possible changes
Although the “Requirements Related to Surprise Billing: Final Rule,” was released on August 19th, the No Surprises Act roll-out is far from complete. Its complexity means adherence, oversight, and enforcement, as well as system and process changes, are still works in progress. And there are additional rules to follow before the consent, good faith estimates for insured patients, and advanced Explanations of Benefits requirements are fully understood.
Despite the uncertainty, consumers should be realizing more affordable healthcare costs in emergency and unintended out-of-network cases. And now both payers and providers are incorporating tools that will enable them to effectively navigate the new requirements of the No Surprises Act. This all adds up to the promise of a win-win-win situation!
Photo: claudenakagawa, Getty Images
Susan Mohler’s tenure at MultiPlan spans more than two decades. During that time, she’s driven significant positioning and product strategies that have helped shape the healthcare industry and how MultiPlan delivers value. As the Senior Vice President of Marketing and Product Management, Susan leads the effort to ensure stakeholders understand the critical role MultiPlan plays in the healthcare ecosystem, and that MultiPlan understands and drives changes to evolve that value. She oversees the company’s product management, sales support, marketing, and communications functions. In addition to these responsibilities, Susan is MultiPlan’s spokesperson on the recently passed No Surprises Act. Her insights on this piece of legislation have helped MultiPlan develop business requirements, implement services, and establish a roadmap to drive continued enhancements. Susan earned her MBA from The Wharton School at the University of Pennsylvania with majors in Marketing and Strategic Planning.
