By now, most of you are surely familiar with the No Surprises Act (NSA), a federal law that protects patients from unexpected medical bills. The Act and its subsequent regulations protect insured patients from getting balance-billed in a number of circumstances, including emergencies.
However, notably, the Act does not include protections for a very common – and expensive – emergency service: that is, when a patient needs a ground ambulance.
Instead, Congress basically set aside ambulance balance billing as an issue that needed to be studied more before policymakers developed laws for it.
To that end, Congress set up the Ground Ambulance & Patient Billing Advisory Committee, comprised of commercial and governmental stakeholders.
Just last week, the Committee came out with a set of recommendations on air ambulance reimbursement.
Now, on the one hand, this makes a lot of sense, as nearly 20 states have adopted laws that apply to ambulance reimbursement.
On the other hand, this makes a complex issue even more complex, especially for health plans that work across multiple states.
Either way, Congress has no plans to pass a law on ambulance reimbursement in the near future.
Another element of the No Surprises Act that was set aside for more consideration was the requirement that providers and payers give patients an estimate on costs before medical services are provided. The NSA called these estimates an advanced explanation of benefits – or AEOB.
Providers are currently required to present advanced cost estimates directly to uninsured or self-pay patients.
However, under the NSA, providers were also required to send good-faith estimates to a patient’s health plan if they were insured, and the health plan was then required to send the member an AEOB explaining member costs.
Like ambulance reimbursement, the government basically put off publishing requirements for the AEOB until it had a chance to think through the issue.
This summer, the government announced it would publish a proposed rule on the AEOB next March. One of the outstanding questions is whether the rule would require providers to send health plans diagnosis codes as part of the advanced good-faith estimates; after all, in some cases, a doctor may not have even seen a patient who is requesting specific medical care, so how is that doctor supposed to send diagnosis codes as part of an advanced price estimation?
Another question is how providers will be expected to send or submit these good-faith estimates to payers. For example, will the government require certain standard electronic formats to be used?
If that’s not enough, the government also expects to publish a new NSA regulation this November that would change nearly every aspect of the Independent Dispute Resolution (IDR) process that providers now access when they disagree with how they were paid for No Surprises Act claims.
Between new expected regulations and ongoing litigation, we expect another busy year in the ever-evolving requirements of the No Surprises Act.
The Medicare Advantage (MA) program has grown significantly over the past two decades, becoming a popular alternative to traditional Medicare fee-for-service (FFS). As of 2023,
The Medicare and Medicaid provider auditing process is about to get a makeover in 2025. I am talking about artificial intelligence (AI), which may be
Please log in to your account to comment on this article.
Join Beth Wolf, MD, CPC, CCDS, for an in-depth webcast on the FY2025 spinal fusion MS-DRG updates. Discover key changes in DRG classification, understand impacts on documentation and CMI, and learn strategies to ensure compliance.
Join Angela Comfort, DBA, MBA, RHIA, CDIP, CCS, CCS-P, as she presents effective strategies to strengthen collaboration between CDI, coding, and quality departments in acute care hospitals. Angela will also share guidance on implementing cross-departmental meetings, using shared KPIs, and engaging leadership to foster a culture of collaboration. Attendees will gain actionable tools to optimize documentation accuracy, elevate quality metrics, and drive a unified approach to healthcare goals, ultimately enhancing both patient outcomes and organizational performance.
Optimize your outpatient clinical documentation and gain comprehensive knowledge from foundational practices to advanced technologies, ensuring improved patient care and organizational and financial success. This webcast bundle provides a holistic approach to outpatient CDI, empowering you to implement best practices from the ground up and leverage advanced strategies for superior results. You will gain actionable insights to improve documentation quality, patient care, compliance, and financial outcomes.
Enhancing outpatient clinical documentation is crucial for maintaining accuracy, compliance, and proper reimbursement in today’s complex healthcare environment. This webcast, presented by industry expert Angela Comfort, DBA, RHIA, CDIP, CCS, CCS-P, will provide you with actionable strategies to tackle complex challenges in outpatient documentation. You’ll learn how to craft detailed clinical narratives, utilize advanced EHR features, and implement accurate risk adjustment and HCC coding. The session also covers essential regulatory updates to keep your documentation practices compliant. Join us to gain the tools you need to improve documentation quality, support better patient care, and ensure financial integrity.
Dr. Ronald Hirsch provides critical details on the new Medicare Appeal Process for Status Changes for patients whose status changes during their hospital stay. He also delves into other scenarios of hospital patients receiving custodial care or medically unnecessary services where patient notifications may be needed along with the processes necessary to ensure compliance with state and federal guidance.
Healthcare organizations face complex regulatory requirements under the No Surprises Act and Price Transparency rules. These policies mandate extensive fee disclosures across settings, and confusion is widespread—many hospitals remain unaware they must post every contracted rate. Non-compliance could lead to costly penalties, financial loss, and legal risks. Join David M. Glaser Esq. as he shows you how to navigate these regulations effectively.
Protect your facility from unwanted audits! Join Becky Jacobsen, BSN, RN, MBS, CCS-P, CPC, CPEDC, CBCS, CEMC, and take a deep dive into both the CMS and AMA guidelines for reporting post operative pain blocks. You’ll learn how to determine if the nerve block is separately codable with real life examples for better understanding. Becky will also cover how to evaluate whether documentation supports medical necessity, offer recommendations for stronger documentation practices, and provide guidance on educating providers about documentation requirements. She’ll include a discussion of appropriate modifier and diagnosis coding assignment so that you can be confident that your billing of post operative pain blocks is fully supported and compliant.
During this RACmonitor webcast Dr. Ronald Hirsch spotlights the areas of the OIG’s Work Plan and the findings of their most recent audits that impact utilization review, case management, and audit staff. He also provides his common-sense interpretation of the prevailing regulations related to those target issues. You’ll walk away better equipped with strategies to put in place immediately to reduce your risk of paybacks, increased scrutiny, and criminal penalties.
Copyright © 2024 RACmonitor. Powered by MedLearn Media.
Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24
