No Surprises Reboot

Blog Thumbnail Pricing Transparency Reboot

The federal No Surprises Act was put in place January 1, 2022. Its sole purpose was to protect unsuspecting patients from out of network bills when care was delivered by non-participating providers that they didn’t anticipate and, in many cases, had no control over (a notable exception to the law was ground ambulance). While it was well intended legislation, the reality is that it has become an ongoing legal fight and an administrative mess for providers.

The legislation has been challenged in court several times and the courts have overwhelmingly sided with providers who have continually said that the legislation is beneficial to payers, creates additional administrative burden for providers and is unnecessarily arduous in practice. At the center of the debate are the dispute resolution process instituted as a part of law as well as the fees associated with filing a dispute.

On October 27th, the Departments of Health and Human Services, Labor, and the Treasury (and the Office of Personnel Management proposed adjustments to the existing dispute resolution framework and fees. A few key points:

  1. Starting Open Negotiations: Parties initiating open negotiations must use the IDR portal to notify the other party and relevant federal departments, making it clearer.
  2. Timely Response: The receiving party has 15 days to respond during the 30-day open negotiation period.
  3. Clear Communication: Payers must use standardized codes to clarify whether a claim falls under the No Surprises Act, reducing disputes.
  4. Grouping Services: Certain services can be grouped together for IDR, simplifying the process.
  5. Limit on Grouping: The proposal sets a cap of 25 services for grouped determinations to keep things manageable.
  6. Quick Eligibility Decisions: IDR entities must decide on eligibility within five business days, and parties must provide requested information promptly.
  7. Fee Collection: Fees will be collected directly from parties, with deadlines for both initiating and non-initiating parties.
  8. Reduced Fees: Lower fees may apply if negotiations result in lower offers or if a dispute is found ineligible.

Getting this implemented correctly has proven challenging. The No Surprises Act is still a work in progress, but these changes aim to make billing dispute resolution process more straightforward and efficient while ensuring fairness for everyone involved.

Interested in learning more? The team at VisiQuate is focusing on how we can help hospitals optimize their revenue cycle management. Visit our Revenue Cycle Playbook for step-by-step plays to help you stay on top of the ever-changing landscape of healthcare revenue cycle, or contact us to schedule a demo.

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