The No Surprises Act takes effect on January 1, 2022
On Dec. 27, 2020, President Donald Trump signed the longest law in the history of the United States, the Consolidated Appropriation Act, 2021, or the CAA. This Act included a provision that required the U.S. Intelligence agencies to release a report on everything the government knows about UFOs.
Late last week, the UFO report was released and… I can’t tell you anything more about it, because my report has to be about healthcare, but you should look it up. It’s interesting.
To wit, the CAA also included the No Surprises Act which prohibits out-of-network providers from balance billing patients in 1) emergency situations, 2) in-network facilities and 3) for air ambulance transport. If, in the state where the out of network services are provided, there are no laws on how a payer should reimburse the provider for these services, the No Surprises Act outlines a federal process for payers and providers can use to negotiate and settle on reimbursement for these out-of-network services.
If the provider is not satisfied with those negotiations, the Act also establishes an arbitration process where a third party decides on a final payment amount.
The No Surprises Act takes effect on January 1, 2022, and this month, the administration set a general timeline for the publication of the first and second regulations that will implement the Act.
The main point of contention with both these regulations will be the calculation and the use of the payer’s median in network rate. Now, a payer does not have to pay the provider its median in-network rate initially for these out of network services. A payer can pay what it wants.
But, if the provider does not like that initial payment amount, and the negotiations fail and the provider wants to go to arbitration, when looking at the payer’s payment offer, the arbitrator must consider the payer’s median in-network rate, along with a list of other considerations such as acuity of the patient, experience of the provider, quality measures.
On the lobbying front, health plans, employers and some lawmakers argue that the median in-network rate should be primary in terms of what the arbitrators should consider when determining a final payment amount. In other words, payers want to pay out-of-network providers the same amount as their in-network providers.
In contrast, hospitals, emergency physicians and other lawmakers argue that the median in-network rate should just be one of many considerations that the arbitrator should use. In other words, out of network providers want to be paid more than what a payer pays in-network providers depending on the circumstance and context of the services provided.
Parts 1 and 2 are interim final rules (IFR), which means that, although industry will be given an opportunity to comment after the rules are published, the regulations will be pretty much baked and the chance of substantially changing any of the requirements with those comments will be slim.
Programming Note: Listen to Matthew Albrights live Legislative Update every Monday during Monitor Mondays, 10 Eastern.
While it is common to have payer contracts include a substantial percentage discount off of your billed charge, the practice creates avoidable risk. Healthcare pricing
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
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 →
