Start your revenue cycle strong by ensuring that critical, and accurate, patient information is in place before patient visits begin.
Health Information Management
Our team of coding experts, with a deep understanding of the healthcare industry and its specialties, paired with smart technology creates a tangible, positive impact on cash flow.
Extended Business Office
AGS Health provides a comprehensive suite of RCM services that are customized for each customer. Our experienced team of experts serves as an extension of your business office.
Analytics and Reporting
Obtain answers to critical questions related to performance benchmarking, root cause analysis, predictive analytics, and operational improvements.
Connect with us
Request a demo
Latest CASE STUDIES
By AGS Health
December 7, 2023
The No Surprises Act (NSA) went into effect on January 1, 2022, as part of the Consolidated Appropriations Act of 2021. The act aims to protect patients from surprise medical bills by setting new standards for payment and dispute resolution. It requires providers and insurers to work together to determine a fair payment for out-of-network (OON) emergency services, certain out-of-network non-emergency services at in-network facilities, OON providers of air ambulance services.
The NSA established a qualifying payment amount (QPA) as the basis for determining a patient’s cost-sharing responsibility for OON services covered by the balance-billing protections. It establishes a “median contracted rate” in geographic region and is based on 2019 contracts and adjusted annually for inflation. Providers are entitled to fair payment under the NSA, but because the patient is only responsible for the in-network amounts, healthcare providers must negotiate additional payment above the QPA with the patient’s insurance company.
The NSA establishes a process for resolving payment disputes through independent dispute resolution (IDR) when an All-Payer Model Agreement or specified state law does not apply. It involves submitting a request to an IDR entity, selecting an entity to serve as an independent arbitrator, submitting information, and taking part in arbitration. The key steps and timeline involved in the process per IDR guidance from the Centers for Medicare and Medicaid Services (CMS) include:
Before the Federal IDR Process
Initial Payment or Notice of Denial of Payment
Must be sent by the plan, issuer, or carrier no later than 30 calendar days after a clean claim is received.
Initiation of Open Negotiation
Initiated within 30 days from the date of payment from plan/carrier.
Open Negotiation Period
Parties are required to exhaust an open negotiation period of 30 business days before either party may initiate the IDR process.
Federal IDR Process Overview
Notice of IDR Initiation
Initiate the IDR process by submitting a notice of IDR Initiation that includes the preferred certified IDR entity to the other party and the Departments of Health and Human Services (HHS), Labor, and the Treasury within 4 business days after the close of the open negotiation period.
Selection of Certified IDR Entity
The non-initiating party can accept the initiating party’s preferred certified IDR entity or object and propose another certified IDR entity within 3 business days for a selection to be made within 6 business days.
Certified IDR Entity Requirements
Certified IDR entity must confirm no conflict of interest and determine that the Federal IDR Process is applicable within 3 business days after selection.
Submission of Offers and Payment of IDR Entity Fee
Parties must submit their offers no later than 10 business days after IDR entity selection and pay IDR entity fees.
Selection of Offer
Certified IDR entity has 30 business days after selection to select one of the payment offers submitted and notify the parties.
Any amount due must be paid no later than 30 calendar days after the determination. Certified IDR entity must refund the prevailing party’s fee within 30 business days.
Managing the NSA dispute process manually can be time-consuming and labor-intensive. This can lead to potential delays and errors, which can cause the provider to lose the ability to appeal the claim and forfeit all rights. The timing of the negotiation and IDR processes is critical because missing deadlines can result in the entire dispute being voided. This puts a significant burden on providers, who must keep track of multiple deadlines and tasks to ensure that disputes are resolved within the stipulated time.
To address these challenges, healthcare providers can leverage the benefits of Robotic Process Automation (RPA) to handle tedious, time-intensive workflows and manage the appeal and dispute process more efficiently. Digital workers, also known as bots, can monitor inbound and outbound mail, log into portals, and submit offers can streamline the dispute resolution process to ensure that all deadlines are met, reducing the amount of time and resources required.
Overall, the NSA represents a significant change in the way healthcare payments are managed. By leveraging RPA through digital workers to handle tedious and repetitive tasks, healthcare providers can streamline the dispute resolution process and workflows and reduce the amount of time and resources required to handle appeals, leading to improved accuracy, efficiency, and compliance. The right automation tools and strategies can also help ensure that the dispute process is handled accurately and on time, reducing the risk of the dispute being voided.
Contact us to learn more about how you can leverage RPA and other automation tools to manage the challenges and administrative burdens associated with the NSA and the dispute resolution process.
AGS Health is more than a revenue cycle management company–we’re a strategic partner for growth. By blending technologies, services, and expert support, AGS Health partners with leading healthcare organizations across the US to deliver tailored solutions that solve the unique needs and challenges of each provider’s revenue cycle operations. The company leverages the latest advancements in automation, process excellence, security, and problem-solving through the use of technology and analytics–all made possible with college-educated, trained RCM experts. AGS Health employs more than 10,000 team members globally and partners with more than 100 clients across a variety of care settings, specialties, and billing systems.