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No Surprises Act: Update

By Debra Stall, CRCR

September 2, 2022

There has been some interesting news about the No Surprises Act that you should be aware of. If you aren’t familiar with the No Surprises Act, I encourage you to read the Understanding the No Surprises Act blog post before proceeding with this one. It will give you the foundational knowledge you need, and it addresses some questions we hear frequently.

AHIP and BlueCross BlueShield Association recently shared a new report based on online survey responses they received in April from 31 health plans (representing 54% of the commercial insurance market). After analyzing and extrapolating data, they estimate the new law prevented more than 2 million potential surprise medical bills during the first two months. The law went into effect on January 1, 2022. When projecting that number over a year, more than 12 million surprise bills could be prevented.

While those numbers seem high, a recent article from Modern Healthcare cites a recent study conducted by the Journal of American Medical Association that shows fewer than 6% of hospitals obeyed the price transparency rule during the early months of implementation.

That leaves me questioning: How many more surprise bills could have been prevented if more hospitals had obeyed the law?

As of January 1, 2022, when NSA went into effect, hospitals were required to “post machine-readable, consumer-friendly files of the rates they negotiated with payers, gross charges, and discounted cash prices for 300 shoppable services.” For larger hospitals that don’t comply, CMS threatened a maximum yearly fine of more than $2 million. For hospitals with fewer than 30 beds, the penalty would be $110,000. The financial threat to a company that does not comply with the NSA certainly adds pressure to hospital staff.

Current Concerns

The NSA, which CMS governs, ensures price transparency so consumers know what their costs for medical care could be – a range for the services provided. But the NSA has some providers arguing they aren’t being paid fairly. There are two factors to consider:

The Public - The public has a right to price transparency. Surprise billing can cost consumers thousands of dollars, sometimes tens or hundreds of thousands of dollars – depending on the medical care being sought. Many consumers have already benefitted from the new law.

Providers Fee for Services - Some providers don’t feel the price cap set by the NSA law reflects fair market value for the medical services provided. Some have already gone to court to fight the law, encouraging arbitrators to use the qualifying payment amount (QPA), which is a median in-network amount for given services in each market, when settling payment disputes.

In response to these lawsuits, the U.S. Department of Health and Human Services (HHS) stated it would soon write new regulations that incorporate other criteria. Some argue expanding criteria to consider QPA could result in unintended consequences, such as restricting access to care by allowing insurers to be increasingly selective about which providers they bring into their networks. Some fear narrower networks could result in fewer doctors, which could be extremely harmful in emergency situations. In rural and underserved communities, narrower networks could be even more detrimental.

Regardless of the path forward, what hospitals need to know at this point in time is that they need to abide by the NSA law and meet the established criteria for price transparency. CMS has created a website to help those managing NSA requirements - https://www.cms.gov/nosurprises.

Debra-Stall

Debra Stall, CRCR

Author

As Senior VP of A/R Service Line at AGS Health, Debra oversees strategic growth initiatives for the company’s Accounts Receivable Services division. Throughout her 30+ year career, she has helped numerous companies drive operational excellence through global outsourcing, strategic planning, and process improvements. Debra’s extensive experience in healthcare management has delivered transformational results for leading healthcare organizations, resulting in significant financial growth with best-in-class operational efficiency.

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