The recently passed No Surprises Act significantly impacts payers such as health insurance companies and self-insured employers who are working to adjust to new rules and establish compliance strategies aligned with the new regulations.
Key provisions of the No Surprises Act that impact payers include:
Obligation for providers and payers to provide transparency regarding the cost of care upfront, in order to help patients make more informed decisions about their healthcare and avoid surprise bills. The act requires payers to deliver an advanced explanation of benefits (AEOB) to insured patients before their date of service; however, enforcement of this regulation has been deferred until more information can be gathered to assist in implementation.1
Requirement for emergency services to be covered at an in-network rate, even if the provider is out-of-network, with no requirements for prior authorization.2
Establishment of a dispute resolution process for resolving payment disputes between payers and healthcare providers. This process is designed to remove the burden of payment disputes from patients. It involves a 30-business-day open negotiation period between payer and provider prior to accessing the Federal Independent Dispute Resolution (IDR) Process (if a resolution cannot be reached during the period of open negotiation). Disputing parties must pay a fee to participate in the IDR process and adhere to strict deadlines for submitting information and initiating disputes.3
These new provisions can impact a payer’s bottom line and may necessitate more administrative work, along with administrative fees. Additionally, a backlog of Federal IDR submissions may result in a prolonged delay for a final resolution of a payment dispute.
Naviquis is here to help. Our end-to-end payment integrity solution helps ensure that health claims are paid accurately, per contract terms – enabling you to avoid costly payment disputes.
By taking a proactive approach, we can prevent incorrect claim payments before they are made. This saves valuable time, lowers administrative costs, decreases provider abrasion, and significantly increases savings.
Contact us to learn more about our secure, automated solution, or for more information on how the No Surprises Act affects payers.
SOURCES:
1 Federal Register. “Request for Information; Advanced Explanation of Benefits and Good Faith Estimate for Covered Individuals.” (2022). Retrieved from https://www.federalregister.gov/documents/2022/09/16/2022-19798/request-for-information-advanced-explanation-of-benefits-and-good-faith-estimate-for-covered
2 CMS (U.S. Centers for Medicare & Medicaid Services). “HHS Announces Rule to Protect Consumers from Surprise Medical Bills.” (2021). Retrieved from https://www.cms.gov/newsroom/press-releases/hhs-announces-rule-protect-consumers-surprise-medical-bills
3 CMS (U.S. Centers for Medicare & Medicaid Services). Federal Independent Dispute Resolution Process: Checklist of requirements for group health plans and group and individual health insurance issuers.” (2022). Retrieved from https://www.cms.gov/files/document/caa-nsa-issuer-requirements-checklist.pdf
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