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No Surprises Act: Impact and Guidance

December 09, 2022 No Surprises Act Impact and Guidance

In December of 2020, Congress passed the No Surprises Act (NSA) to create new federal protections against surprise medical bills beginning in January 2022. The law is intended to protect insured consumers from surprise medical bills when they receive out-of-network emergency services and items, out-of-network services provided at in-network facilities that they have not approved, and air ambulance services for out-of-network providers they did not choose. While the rule removes the patient from payment disputes, it puts the responsibility on the provider or healthcare facility and their health plan to negotiate claims settlements, leading to some unintended consequences.

Unexpected Demand for the IDR Process

By now, anyone already mired in the complexities of the No Surprises Act (NSA) knows one thing for certain: the IDR process is very messy and it's taking much, much longer to resolve claims than the CMS originally anticipated.

Initially, the government estimated around 22K disputes for the entire year. To date, since the CMS's portal launched in April of this year more than 90K disputes have been initiated. 41K of those claims were challenged by the payors and 22K of these were found to be ineligible by the IDREs leaving them with tens of thousands of cases still under review. Only 3.5K determinations have been finalized leaving payors and providers waiting for determinations on tens of thousands of cases sent to the IRDEs to review.

Increased Emergency Department Visits

While experts predict that the NSA could result in $5.1 billion in savings, changes in patient behavior because of the law could offset much of the cost savings. Without fear of receiving surprise bills for out-of-network emergency services, patients will probably more likely to visit emergency room departments for less urgent cases.

Emergency Room Entrance

This prediction is based on the experience of insurers (HMOs) in states that have prohibited balance billing since at least 2007. A recent study compared Emergency Department (ED) visits in 15 states with balance billing bans between 2007 and 2018 to ED visits in 16 states without bans to examine the domino effect of the significant reduction in out-of-pocket payments under the NSA. Though the bans in the 15 states reduced spending per visit by 14%, ED visits increased by 3%. The savings generated in reduced amounts paid per claim is largely offset by the increased utilization of emergency department services.

Avoiding Potential Adverse Outcomes

Working with an expert cost containment company to negotiate claims on their behalf is the way for payors to avoid arbitration and other costs, time-consuming process and potentially unfavorable IDRE decisions.

With a strict bill payment resolution timeline, the key to successful negotiation starts by getting those large NSA claims to the cost containment company as soon as they are received. Here's the IDR process at a glance:

  • Non-participating Provider (NPP) sends Plan the bill for OON services.
  • Within 30 business days of receiving the bill: Plan must make initial payment or deny the bill.
  • Within 30 business days of receipt of payment or denial: Either party may initiate open negotiations.
  • 30 business days: open negotiation period.
  • Within 4 business days of end of negotiation period: Either party may initiate IDR.
  • Within 3 business days of IDR initiation: Parties select IDRE (or HHS selects IDRE within 6 business days of initiation date).
  • Within 10 business days of IDRE selection: Parties submit offers for payment with other information to IDRE.
  • Within 30 business days of IDRE selection: IDRE selects one of the party's offers.
  • Let Us Work For You

    H.H.C. Group Can Help You

    A prompt and properly executed NSA claim negotiation strategy can save both you from the effort and hassle of dealing with your large NSA claims, while eliminating the possibility of adverse, potentially costly IDRE determinations. When NSA claims are sent to HHC as soon as they are received it takes our Case Managers 5 days or less to contact the provider to a secure signed settlement. In cases for which a settlement cannot be achieved that leaves plenty of time to still make an initial payment during the first 30-day period.

    If a provider initiates Open Negotiation, HHC's highly experience Case Managers can go to work to convince payors to accept an appropriate amount for their services and avoid rolling the dice with the IDRE. When requested, we'll even attempt to negotiate a settlement even if the claim has been sent to the IDRE for resolution.

    With almost 30 years experience successfully negotiating medical bill settlements on behalf of payers, we're your NSA experts. Call us at 301-960-7092.