Why the No Surprises Act Matters for Healthcare Providers?
Valerion Health
November 30, 2023
Did you know that the US healthcare industry is the most expensive in the world? The average healthcare spend in the US rounds up to about $12,900 per person. By comparison, the same cost in other wealthy countries is about half as much. High healthcare costs in the US continue to be a hindrance in seeking medical care, often pushing people to delay treatment.
Recently, a study by Gallup, a global analytics and advisory firm, showed that over 40% Americans skipped medical care in 2022 due to high costs of treatment. Around the same time, the No Surprises Act (NSA) was introduced to help tackle this issue.
To describe it briefly, the NSA is a protective bubble around the patient’s healthcare expenses. It restricts out-of-network providers from billing patients more than their in-network amount.
This means that from January 1, 2022, it became illegal to bill patients more than in-network cost sharing. If we talk about NSA with regard to healthcare providers like you, it allows them and insurers to negotiate reimbursement separately with the help of an independent dispute resolution process.
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Did you know that the US healthcare industry is the most expensive in the world? The average healthcare spend in the US rounds up to about $12,900 per person. By comparison, the same cost in other wealthy countries is about half as much. High healthcare costs in the US continue to be a hindrance in seeking medical care, often pushing people to delay treatment.
Recently, a study by Gallup, a global analytics and advisory firm, showed that over 40% Americans skipped medical care in 2022 due to high costs of treatment. Around the same time, the No Surprises Act (NSA) was introduced to help tackle this issue.
To describe it briefly, the NSA is a protective bubble around the patient’s healthcare expenses. It restricts out-of-network providers from billing patients more than their in-network amount.
This means that from January 1, 2022, it became illegal to bill patients more than in-network cost sharing. If we talk about NSA with regard to healthcare providers like you, it allows them and insurers to negotiate reimbursement separately with the help of an independent dispute resolution process.
What Does the No Surprises Act Entail?
Now that we know what the act is, let us take a closer look at what it entails:
Out-of-Network Billing
Under the act, patients are safeguarded from unexpected and often expensive bills when they receive care from out-of-network providers.
Cost Transparency
The act encouraged transparency by asking healthcare providers to provide a good faith estimate of expected charges for services to self-pay or uninsured patients. This allows patients to make informed decisions and encourages them to seek treatment at the right time.
Independent Dispute Resolution (IDR)
The act introduced an IDR process to settle payment disputes between healthcare providers and insurers to ensure fair compensation for out-of-network services.
Continuity of Care
It warrants that patients undergoing ongoing active treatments with an out-of-network provider get treated without any disruptions.
Advance EOBs
NSA also enabled patients to receive an Advance Explanation of Benefits (EOB) that outlines their cost-sharing responsibilities and estimates of provider charges before non-emergency scheduled care.
Challenges with No Surprises Act
Although the act was introduced to make seeking healthcare easier, it ended up creating several hurdles.
- Care complexity: Providing a patient with in-network care that involves multiple providers can prove to be difficult as it requires thorough documentation and precise communication
- Payment negotiations: The mandated negotiations between payers and healthcare providers are often prolonged, making the whole process cumbersome and slow
- Billing discrepancy: Complex billing procedures, especially involving out-of-network services can result in inaccurate billing and claim denials
- Education and training: Healthcare organizations are forced to provide training and education materials for employees to ensure that they are up to date with the latest regulations.
- Non-compliance: Non-compliance with the NSA can result in penalties worth $10,000 for single violations and even exclusion from networks
Apart from these challenges, the NSA faced legal trouble from the American Medical Association (AMA), American Hospital Association (AHA) and Texas Medical Association (TMA). They initiated legal actions over the unfair process to resolve billing issues between insurers and healthcare organizations.
In a statement released by AMA, they mentioned how they supported “protecting patients from unanticipated bills” but insisted on how it could “significantly raise out-of-pocket expenses and threaten access to quality care”.
After several lawsuits with varying rulings, the NSA still has some unexpected financial gaps that can be manipulated.
Can Outsourcing Help Comply with No Surprises Act?
When the Health and Human Services (HHS) opened its Independent Dispute Resolution (IDR) portal to handle NSA-related insurer and healthcare provider disputes, it received over 90,000 claims in five and a half months. It was well over the estimated claims for the whole year.
At the end of the day, more claims can mean more work for employees working in healthcare organizations. This is where outsourcing can play a critical role in helping organizations like yours to comply with the NSA.
By outsourcing functions like coding and billing, you can decrease the burden of administrative work on employees and enable them to focus on patient care.
Apart from that, outsourced coders are usually well-versed with the latest updates and regulations and can navigate challenges properly. This would also eliminate any additional investment that would otherwise go to educate or train employees. Outsourcing can play a pivotal role in helping streamline processes and help stabilize income for your organization.
Moreover, outsourcing solutions help reduce costs that come with employee benefits or other such expenses. To reap all of these benefits, you must choose the right outsourcing partner that can cater to your organization’s needs. To know more about the dos and don’ts in choosing a healthcare outsourcing partner, read now.
Key Steps to Streamlining Compliance
All the penalties, lawsuits and pending claims make it important for your organization to comply with the NSA. To help with this, we have created a list of key steps that would make compliance easy and efficient.
Compliance Audit
Conduct a comprehensive audit of your organization to understand and recognize the areas that need improvement. You can also hire outsourcing professionals to audit or review your organization’s framework.
Develop and Launch a Compliance Plan
Once it is known what areas need work and improvement, you can discuss them with the stakeholders and heads of departments to gain essential insights into unforeseen challenges. The compliance plan should have detailed steps, namely mention of responsible parties and open channels of communication and issue addressal. Implementation of HIPAA and other such acts to ensure safety of patient records.
Monitor and Report
The compliance plan should include timely updates of strategies and other updates so that you are aware of what is happening. It is encouraged to review and update policies as and when needed.
Compliance is an ongoing process that needs consistent supervision. But it helps reduce the risk of legal and financial troubles, promotes accountability, boosts productivity and safeguards patients’ data among other things.
Key Takeaways from the No Surprises Act
You remain vigilant about the latest developments that happen around the act as non-compliance can result in civil monetary penalties of up to $10,000 per violation. Partnering with the right outsourcing partner can save the organization from violations while streamlining the process.
At Valerion Health, we boast over 20 years in the healthcare industry. We have a team of expert coders and billers who can help you navigate through the challenges that come with NSA and streamline your process. We also provide customized solutions, so you get the best out of the partnership. Contact us to know more.
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