On Jan. 1, 2022, the No Surprises Act will take effect.
It prevents patients from receiving large, unexpected bills from out-of-network providers. Providers must prepare now to navigate the new system, shoring up their knowledge on regulations, establishing workflows to stay on top of complex submission and arbitration processes and resolving to be persistent.
During an August webinar hosted by Becker's Hospital Review and sponsored by Collect Rx, Richa Singh, executive vice president at Collect Rx, discussed out-of-network reimbursements, no surprise billing and ways providers can prepare now.
Ms. Singh explained that industry factors have reduced out-of-network provider reimbursements. "Insurance companies are putting up all sorts of roadblocks to make it difficult for providers to get their due payments," Ms. Singh said. These roadblocks include payer and repricing company restrictions, industry consolidation resulting in fewer options, mid-year policy changes, conditional patient authorization form requirements and third-party allowable increase limits.
She continued by describing how the No Surprises Act combines multiple provisions with complex dispute resolution process. "The goal of the No Surprises Act is to eliminate medical bills received from out-of-network medical providers that the patient did not willingly choose," Ms. Singh said. Nearly all private health plans will be affected, and the dispute resolution process involves multiple steps with tight timeframes.
Ms. Singh indicated six ways for providers to prepare for the No Surprises Act.
1. Providers must actively negotiate out-of-network bills to the highest reimbursement levels. Payers are already using complex computer algorithms to determine which tactics yield the lowest payments and are tracking this information to "use that as justification in 2022," Ms. Singh explained. In response, providers must counter these payer efforts to ensure that out-of-network payments are commensurate with services by:
- Being persistent. "It's all about a battle of the wills," Ms. Singh said. "Your lower reimbursement means they get higher commissions, so when you give up, they win. When you get negotiation offers, make sure you're responding to all of them, and stay on top of appeals."
- Hiring specialized out-of-network staff. "It's a whole different ballgame from managed care contracts," she added. Understanding historical reimbursement, when and how to communicate with payers and the appropriate time to escalate is critical.
- Tracking comparable data. Look at usual and customary allowances.
- Obtaining patients' authorization forms early. Each time of service requires a form, and electronic signatures may not be accepted.
- Establishing a rigorous appeals process. Keep documentation organized, obtain explanations, devise strategy and follow up.
- Terminating third-party agreements. Often, these contracts will cap reimbursements.
2. Providers can prepare by being educated on new state and federal laws and staying current on subsequent regulations to ensure they are fully exercising their rights. Professionals such as Collect Rx or a legal group well versed in healthcare law can help.
3. Providers must identify eligible cases, adhere to strict submission timelines and leverage data and analytics capabilities during settlement negotiations.
4. Providers must track independent payer workflows including how to simply submit information and deadline requirements.
5. Providers must analyze the cost of the arbitration process, which includes mediator expenses paid by losers. Bundling cases together can help make the arbitration effort more worthwhile.
6. Providers must track results for future cases and appeals.
By taking these actions, providers will be better positioned to deal with the changes in the No Surprises Act.
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