End-to-end support for the No Surprises Act
The No Surprises Act (NSA) adds a new level of complexity to paying healthcare claims. From identifying surprise bills to offering support during arbitration, MultiPlan’s services address the entire lifecycle of a surprise bill.
Our End-to-End Surprise Billing Service
With expertise in every step of the process, we can administer the entire NSA process on your behalf. Our easy-to-implement services can help your organization achieve compliance quickly.
Identify Surprise Bill
Calculate and Append QPA
How our flexibility helps you meet the new requirements
The No Surprises Act became effective January 1, 2022. How have the requirements impacted your operations? Whether you leverage our end-to-end (No Surprises Act) NSA services or partner with us for specific needs, our flexible approach can simplify things for you. Our team works with your organization to determine the right solution to help your organization comply.
This isn’t new to us. In fact, we’ve been supporting our clients with many of these services for years. Whether negotiating to avoid arbitration, building complementary networks or determining the appropriate payment amount, we’re experts and can deliver top-level support for your organization’s NSA support needs. Let us build a NSA Machine that will work for your organization.
Surprise medical bills occur when patients are treated by out-of-network (OON) providers under circumstances where they are unable to plan for or avoid the OON service (e.g., emergency care). Surprise bills can also occur when a patient is unknowingly treated by an out-of-network provider at an in-network facility such as a hospital. Usually, the out-of-network provider sends a bill to the patient’s insurance company, which pays a certain amount for the services. The remainder, or balance, of the bill is then sent to the patient.
The NSA covers claims related to emergency services from the point of a patient’s evaluation and treatment until they were stabilized and can consent to being transferred to an in-network facility. It covers air ambulances but not ground ambulances.
The NSA also covers claims related to non-emergency services when they are provided at an in-network facility by an out-of-network provider.
The new law is effective for health plan years beginning on or after January 1, 2022.
QPA is a term introduced by the No Surprises Act (NSA). It is the plan’s median contracted rate for a specific service in the same geographic region within the same insurance market — the middle amount in an ascending or descending list of contracted rates, adjusted for market consumer price index in urban areas (CPIU). It’s important because it is one of the factors considered during the arbitration process if a provider does not agree with the payor’s initial payment, negotiations are unsuccessful and the Independent Dispute Resolution process is invoked. In most cases, the member cost share is based on QPA rather than the allowed amount. QPA is also used to determine member cost share.
Payors and providers go to arbitration under the NSA when they cannot agree on the amount of a payment for the providers’ services. Before bringing a case to arbitration, the parties must try to negotiate a settlement on their own. Either party has up to 30 days after the payor makes an initial payment to begin the negotiation process, and the negotiation must be open for at least 30 days. If the two sides can’t negotiate a settlement, either party can initiate the independent dispute resolution (IDR) process, also known as arbitration.
Does the No Surprises Act apply to plans that don’t use networks/reference-based pricing without a network?
Yes. The Interim Final Rule (IFR) published in July 2021 and a FAQ published with the August 19, 2022 Final Rule made clear that the No Surprises Act applies to claims that don’t use a network. The requirements are primarily limited to emergency services and air ambulance services for health plans that do not use a provider network, or that use a partial network (e.g., providers only, but no facilities). However, the IFR also stated that agreements between the RBP vendor and a facility would have to be considered as an “in network” facility for purposes of identifying surprise bills. The FAQ further clarifies that these plans are expected to use the QPA as required under the NSA – to determine the member’s cost sharing and as disclosure to the provider with reimbursement. The departments direct these plans to use an eligible database to calculate QPA.
If members receive a balance bill for a service covered by the No Surprises Act, what should they do?
We recommend that the member contact their health plan or visit https://www.cms.gov/nosurprises/consumers for information.
Under the No Surprises Act (NSA), the member’s cost share of claims that qualify as surprise bills must be based on what the new law calls the Recognized Amount (RA). For most ERISA plans, the RA is the lesser of billed charges or the Qualifying Payment Amount. For insured claims regulated under state surprise bill laws or All-Payer Model Agreements, or ERISA plans that have opted in to such laws, the RA may be determined by the state law.
The requirement relating to machine readable files is related to the Transparency in Coverage mandate, not the NSA. The mandate requires health plans to post the following files publicly in non-proprietary machine
readable format and update the files monthly.
- In-network negotiated rate files
- Out-of-network allowed amount files
- In-network negotiated prescription drug files
The effective date of this requirement has been postponed from January 1, 2022 to July 1, 2022.
New requirements began in January 2022
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