While the intent of the No Surprises Act (NSA) has been to safeguard patients against surprise bills for certain services, it continues to cause revenue cycle management (RCM) bottlenecks that providers must address, says Riza Mohammed, general manager at Global Healthcare Services.
“One of the problems is that most insurance companies don’t always follow the NSA,” Mohammed explains. “They process certain claims as standard out-of-network claims rather than NSA-protected claims.”
In a letter to HHS and other federal agencies, the American Medical Association (AMA) and others concur that health plans are circumventing the statute with harmful policies that shift costs onto patients and undercut independent physician practices. Here’s an AMA summary of the letter. These groups call for increased federal agency enforcement and greater transparency around the independent dispute resolution (IDR) process and calculation of the qualifying payment amount (QPA).
Mohammed explains one of the ways in which payer noncompliance can occur: Payers issue out-of-network (OON) claim denials for NSA-protected claims (i.e., claims that include place of service [POS] codes 19, 21, 22, 23, or 24). Then they generate an Explanation of Benefits (EOB) that incorrectly assigns excessive responsibility to the patient instead of the much lower in-network cost sharing amount.
With an incorrect EOB:
If a provider balance bills a patient for an NSA-protected service, there could be several consequences, such as:
For every 100 NSA-eligible claims, Mohammed says payers process approximately 60 incorrectly.
To promote revenue integrity and maintain patient relationships, Mohammed says providers must:
Accurate POS codes are especially important under the NSA because they help determine whether a claim is subject to the law’s surprise billing protections and, consequently, whether the claim may even qualify for the federal IDR process that gives providers a mechanism to challenge out-of-network payments they believe are inadequate. The patient remains responsible only for the applicable in-network cost-sharing amount regardless of the IDR outcome.
Including NSA eligibility edits and EOB audits in the patient billing workflow helps providers catch payer processing errors before inaccurate patient statements are generated. Beyond compliance, NSA eligibility edits and EOB audits help providers:
Certain services deserve heightened scrutiny because they are among the most common claim types subject to the NSA and frequently involve situations where patients have little or no ability to choose the provider. This includes claims for the following services:
Errors in payer adjudication, network status identification, or patient cost-sharing calculations can create significant compliance and revenue cycle risks.
Keep an eye on the percentage of claims each payer reprocesses after OON denials—and the amount of time
it takes the payer to reprocess. “When there’s a trend of sustained noncompliance or increasing days in A/R, greater intervention may be necessary,” says Mohammed. “Leverage these KPIs when asking the payer how it can expedite the process.”
“This significantly reduces costs for the provider,” says Mohammed. “Consolidate and batch the claims all in one group so payers can process them all at once.”
A new final rule decreases IDR fees from $115 to $15 per party per dispute, speeds up eligibility checks to five days, expands claim batching, and boosts transparency to fix No Surprises Act bottlenecks.
As payers continue to struggle with accurate NSA claim adjudication, providers must proactively identify NSA-protected claims, verify place of service coding, audit EOBs and patient responsibility amounts, monitor high-risk service lines, and track payer reprocessing performance. Organizations that implement strong revenue integrity controls, leverage the IDR process appropriately, and stay current on evolving NSA regulations can reduce compliance risk, protect patient relationships, and minimize revenue leakage caused by incorrect out-of-network claim processing. Learn how Global Healthcare Resource can help.
