The No Surprises Act is No Surprise

John Doe is an inpatient at a hospital. He and his family might have a handle on services and treatments that were actually seen performed, or at least known about such as surgeries.

Then it happens: either on being discharged or after John has been home for a period of time, he’s alerted to an array of behind-the-scenes items about which he wasn’t aware, and then balance billed on those items including charges by out-of-network providers.

Surprises are great for birthday parties but these surprises could almost put John back in the hospital. The No Surprise Act (NSA) will take care of that.

So, whether you’re deeply involved in your setting’s revenue cycle management (RCM) effort or even if you’re a casual RCM observer:

Things to Know

The federal government (see below re individual states) recently released an NSA interim final rule containing information on the nuances for complying including:

• emergency and post-stabilization services to be covered by the NSA
• how any state laws with NSA overtones may also apply
• the requirements for calculating the Qualifying Payment Amount (QPA/see next section)
• the Notice-and-Consent (N&C) process when an out-of-network provider bills a patient in excess of the patient’s applicable in-network cost share 

QPA and N&C for RCM Administrators

• QPA = the median contracted rate paid by the patient’s plan in 2019 for the procedure or service in the same geographic area
• the QPA calculation will be needed to evaluate and establish maximizing revenue and will help determine the patient’s cost share amount for out of network services
• As for the N&C process, it’s highly regulated and very specific; at times patients can actually opt-out of being protected by the NSA

Back to State Laws

• the interim final rule leaves open a discussion on how any state laws will apply especially in calculating the QSA
• since there are lots of state laws on balance billing protection, those will need to be applied along with the federal NSA guidelines but which laws will apply to what charges aren’t clearly defined in the interim final rules

Arbitration Details are Scant

• there is an independent dispute resolution (IDR) process but those nuances aren’t due until 12/27/21 even with the NSA scheduled to go into effect just few days later
• yet incredibly, the IDR could account for as much as two thirds of out-of-network NSA claims

Chiming in is Okay and Even Encouraged

• the Federal Register is scheduled to publish “Requirements Related to Surprise Billing, Part 1" on July 13
• comments can be submitted up to 60 days thereafter and until 5:00 p.m. on the 60^th day for those comments to be considered

Your facility’s RCM administrators should be at least somewhat, if not very familiar at this point with the NSA and its facets. Again, see the NSA interim final rule for any clarifications and details.

Next Steps

To learn more about Revenue Cycle Management, check out our article, “A Complete Walkthrough of the Healthcare Revenue Cycle Management Steps." There, you will learn how to apply our 7 step process, beginning with engaging with an RCM service (think “MedicsRCM!”) or an in-house system on your server or in the cloud (such as MedicsPremier!).

Articles you might also like:

• 10 FAQs about Revenue Cycle Management Services
• Importance of Revenue Cycle Management in Healthcare Industry
• Medical Billing is Only Part of the Revenue Management Cycle