How Will the Federal No Surprises Act Affect Anesthesia Billing?

How will the Federal No Surprises Act affect anesthesia billing

How Will the Federal No Surprises Act Affect Anesthesia Billing?

How Will the Federal No Surprises Act Affect Anesthesia Billing?

Medical providers and insurers have had months to evaluate and debate the Federal No Surprises Act that took effect Jan. 1, but there is potential for many surprises to doctors and administrators as they prepare their billing operations for the new year.

The law attempts to protect consumers from receiving so-called “surprise” bills for services received most often during emergency procedures from out-of-network providers. In the past, insurers would pay only a portion of the actual charge, leaving providers to bill patients for the rest, sometimes long after the procedure.

These bills, unexpected by patients who were for the most part only vaguely aware of out-of-network vs. in-network coverage, caught the attention of federal legislators. One of the big changes enacted with the law is a new method for disputed billing that protects the patient but seems to give an advantage to the insurer over the medical provider.

This will be of particular interest to anesthesiologists, who are often called on for out-of-network procedures during emergencies.

New timelines for payment & negotiation

Following the insurance payment, the law sets out a detailed calendar that all sides must follow:

  • The provider and insurer have 30 days after a denial or payment to negotiate a settlement.
  • If the negotiation does not result in a resolution, the insurer or provider may request an Independent Dispute Resolution (IDR) from an arbitrator. The request must be made within four days of the end of negotiations.
  • After an IDR is granted, both sides have 10 days to supply their numbers along with information supporting their positions.
  • The arbitrator has 30 days from the beginning of the IDR process to choose which side wins.
  • Payment must be made within 30 days of the IDR decision.

Our next blog will describe in more detail the rules of Independent Dispute Resolution, and what it could mean for anesthesiologists.  To get notified when the next blog will publish, please follow our company page at: https://www.linkedin.com/company/medi-corp-inc

Many medical practitioners are distraught about the lack of clarity on the long-term effects of the No Surprises Act will be. One thing is for sure: it will definitely change the way medical billing is done today.

Why medical providers worry about No Surprises Act

 

Many medical practitioners are distraught about the lack of clarity on the long-term effects of the No Surprises Act will be. One thing is for sure: it will definitely change the way medical billing is done today.

We’ve explored the new billing & negotiation timeline in a previous section. Now we’ll look at the dispute resolution process.

Independent Dispute Resolution (IDR)

IDR is the new mechanism set up by the law. It requires the insurer to pay or deny the bill within a month. The payment must be based on in-network benefit levels. So far, it’s pretty clear.

How the benefit levels are determined, however, is a source of contention.

That’s because the initial payment by the insurance company to the doctor will mirror its Median Contracted Rate for the medical procedure. This number is based on 2019 contracted rates.

When only the lower-priced provider groups are included in the average rate for various procedures, the overall rate will go down.

(Note: Patients will be out of the billing picture now, except for copays, deductibles and similar charges.)

To interested observers of the new law, all is not lost. Independent Dispute Resolution, as written by Congress, allowed medical providers to make a case for higher fees than insurers offered to pay. Teaching hospitals, for instance, spend more per patient. Some providers get more of the most difficult cases and should be paid more.

The arbitrator would decide for one side or the other (with administrative fees paid by the loser) and the insurers and medical professionals could not bring another case to Independent Dispute Resolution for 90 days, a cooling off period that would allow the sides to negotiate further for future positioning.

The lawmakers’ grand vision was disrupted over the summer, though, by the Department of Health and Human Services (DHS), which was tasked with writing more rules of guidance before the law took effect.

DHS took the side of the insurers. Its regulators decided that the median contracted rate, set by insurers, would be the final rate unless the medical provider could demonstrate that their services were “materially different” than the usual procedure.

Members of Congress from both parties filed a complaint asking DHS to allow the law to take effect as originally written. The American Hospital Association, American Medical Association, and others have filed lawsuits to restore the intent of the law or delay implementation.

Should anesthesiologists consider a new alliance?

“No Surprises” is causing some anesthesiologists, radiologists, and other professionals to consider joining insurer networks because they will not be able to benefit from working as out-of-network healthcare providers. At Medi-Corp, we understand that many medical practitioners are distraught about the lack of clarity on the long-term effects of the No Surprises Act. This has changed the way medical billing is done today for anesthesiologists in particular.

If you want to talk through options with our anesthesia billing experts at Medi-Corp or if you have concerns about the impacts of this act, please contact us to set up a consultation at 877-684-9114 or visit our website at https://medi-corp.com/. We ensure that we set up our anesthesia and pain management groups for success regardless of what the current legislation is.

(877)-684-9114