The No Surprises Act, which was signed into law in December 2020, won’t go into effect until at least January 1, 2022. But that isn’t slowing down provider groups from working to ensure the details of the bill, which will be administered through by agencies like the Departments of Health and Human Services (HHS), Labor, and Treasury, are ironed out with their interests in mind.
Surprise Billing Task Force
The American College of Emergency Physicians (ACEP) has teamed up with the Emergency Department Practice Management Association (EDPMA) to form the EM SMB (Surprise Medical Billing) Implementation Task Force. This task force also includes experts on insurance, billing, and other aspects of the healthcare marketplace, including CIPROMS, who are working through the legislation to develop an advocacy strategy through the regulatory and rule-making processes.
According to Jeffrey Davis, Director of Regulatory Affairs at ACEP, the Task Force was divided into five workgroups that have met together to establish several major initial recommendations on “key issues expected to be included in the first round of regulations” with “unique and significant implications for emergency care.” Those recommendations were drafted into a letter that was sent to the federal agencies implementing the law.
The following issues are among those addressed in the letter, Davis says:
- Addressing unique aspects of emergency care, like EMTALA, the prudent layperson standard, and the treatment of downgraded claims.
- Defining terms like Qualifying Payment Amount, Recognized Amount, Initial Payment and Denial of Payment, and Audits of Plan Calculation.
- Envisioning federal/state law interaction, including a definition of “Specified State Law,” as well as treatment of ERISA Plans in states where there is a specified state law.
- The Independent Dispute Resolution (IDR) Process, addressing IDR Entity Certification Criteria, batching, the definition and weighting of IDR Payment Determination Criteria, protection from unreasonable plan payments during the cooling-off period, and enforcing IDR Determinations.
- Administrative processes, like reducing administrative burden, identifying plan type of EOBs, and provider enrollment time
- The use of state All-payer Claims Databases (APCDs), along with APCD reporting requirements, and access to Data.
What Providers Can Do Now
In addition to working with regulatory agencies to shape the application of the legislation, a new Regulatory Insights report by Price Waterhouse Cooper (PWC) outlines the implications for providers, including some possible actions to take now while the regulations are being worked out.
First, PWC says that consumer trust and relationship building are key elements of any provider response. As frustrating as out-of-network balance billing is for providers, it’s even more so for patients and guarantors.
“Provider education efforts should focus on adding more … clarity for consumers, to help build long-term trust that strengthens … patient relationships,” PWC says.
Also, providers should improve billing processes to ensure accuracy. Since good-faith cost estimates will be required for non-emergency providers, having data systems that can accurately deliver these estimates, as well as accurately verify a patient’s insurance coverage, will be essential once the No Surprises Act takes effect.
Finally, PWC recommends providers take a data-driven view of the healthcare market and their own payer reimbursement to strengthen their arbitration strategy. As price transparency laws take effect, providers will increasingly have access to pricing data across the industry that can inform their efforts. At the same time, digging into their own payer data can help them gauge average prices to submit in the IDR Process.
For more information about the implications of the No Surprises Act, check out the following resources:
- The EM SMB Implementation Task Force’s letter to federal agencies that are implementing the law.
- Price Waterhouse Cooper’s Secrets of Healthcare Pricing Revealed
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