No Surprises Act: A Closer Look

In the last edition of From the Field, I provided a very brief synopsis of the No Surprises Act that will be making its way to many medical practitioners in January 2022. Nephrologists, like many other specialists who round at hospitals, will likely be directly affected by this new law. While this law does present several challenges, there are also opportunities to collect reimbursement that might not have been collectable before.

It is not uncommon for the nephrologists that my company bills for to see patients during their hospital rounds whose insurance considers the hospital to be in-network but the nephrologist to be out of network. Often, these scenarios end with the nephrologist’s bill to the insurance company being applied to the patient’s large out-of-network deductible—and the provider is left to try and collect reimbursement from patients who are often too ill to work or respond to their bills. Under the No Surprises Act, providers have an opportunity to negotiate reimbursement at an in-network rate with the insurance company and remove the patient from the reimbursement dispute process.

No Surprises Act Key Timelines

To use the No Surprises Act to your advantage, there are a few key points that your billing/administrative staff should be aware of.

  • The health plan must be one that is under the jurisdiction of the No Surprises Act (see the last edition of From the Field for details).
  • The health plan and the provider have 30 days to negotiate a reimbursement rate. By the end of the 30-day time frame, the health plan will issue either a payment or denial to the provider.
  • In the event the provider disagrees with the reimbursement provided by the health plan, the provider has 4 days to initiate an independent dispute resolution (IDR) process to obtain a different reimbursement rate.
  • There is no minimum payment threshold to initiate the IDR process, and similar claims can be batched together.
  • In the IDR process for the No Surprises Act, each party submits one offer and the arbiter selects one of the offers. The arbiter’s decision is final and cannot be appealed.
    • In determining the rate to select, the arbiter may consider the “qualifying payment amount”—which is based on the median in-network rate for the health plan—for the same service in the same geographical area. However, this information is provided by the insurance plan and the arbiter may not consider the usual and customary rates or the Medicare rates in their decision.
  • A provider is not allowed to initiate another arbitration for 90 days against the same carrier for the same services, but all claims that occur during the 90-day cooling period are eligible for IDR after 90 days.

Maximizing Opportunities in the No Surprises Act

Now that we’re aware of some of the key deadlines, here are some steps nephrology practices can take to maximize the opportunities presented by the No Surprises Act:

  • Identify the health plans your providers most commonly encounter in scenarios that qualify for the No Surprises Act and ensure all billing staff are aware of and familiar with these plans.
  • Develop an alert system to notify your key staff of the receipt of reimbursement from the plans identified in the previous step.
  • Review the payments received and decide if you agree with the reimbursement. If not, initiate the negotiation process with the health plan.
  • In the event the negotiation process does not result in a satisfactory outcome, initiate an IDR within the four-day time frame.
  • During the 90-day cooling period, keep track of claims that come out of the provider/health plan negotiation process with an unsatisfactory outcome so they may be included in IDR at the end of the 90-day period.

The keys to maximizing opportunities in the No Surprises Act are awareness of the timelines, identification of the process your office will follow, and teamwork in following your identified process.

Sarah Tolson is the director of operations for Sceptre Management Solutions, Inc., a company specializing in billing for outpatient ESRD dialysis programs, nephrology practices, and interventional nephrology. Your questions are welcome, and she can be reached at [email protected], 801.775.8010, or via Sceptre’s website, www.sceptremanagement.com.