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Leveraging Automation to Manage the No Surprises Act Dispute Process

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:

Step

Action/Timeframe

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.

Payments

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.

Source: https://www.cms.gov/cciio/resources/regulations-and-guidance/downloads/federal-independent-dispute-resolution-process-guidance-for-certified-idr-entities.pdf

Source: https://www.cms.gov/cciio/resources/regulations-and-guidance/downloads/federal-independent-dispute-resolution-process-guidance-for-certified-idr-entities.pdf

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.

Benefits of Automation in Managing the NSA Dispute Process

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.

The significant benefits of implementing RPA include:

  1. Faster Turnaround Time: The NSA dispute process can be overwhelming, requiring the management of potentially countless emails and spreadsheets. Automation tools can help track the negotiation progress and help accelerate the dispute process by reducing manual processing time. AI-powered tools can handle tedious and repetitive tasks such as data entry, document processing, and information retrieval. This can help minimize the administrative burden and reduce the overall turnaround time for resolving disputes.
  2. Improved Accuracy: Errors in the dispute process can lead to delays, resulting in higher costs. Automation can help improve accuracy by reducing the risk of errors in data entry and processing. This can help ensure that disputes are resolved fairly and transparently, promoting trust and confidence.
  3. Enhanced Compliance: The NSA has strict timelines and requirements for the dispute process. Failure to comply with these requirements can lead to penalties and legal disputes. For example, once the IDR process is initiated, the healthcare provider has ten days to make the actual payment. Automation tools can help track the payment process, ensuring that the payment is made on time to prevent the dispute from being voided, and can help ensure compliance by providing real-time alerts and notifications for deadlines and requirements to avoid costly mistakes.
  4. Scalability: The dispute process can be complex and time-consuming, especially for large healthcare providers. Automation can help scale the process by enabling digital workers to handle high volumes of requests and data processing to help improve efficiency and reduce costs.

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.

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AGS Health

Author

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.

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