ACE Alert, October 14, 2021 Volume 42
Start Working Now…..
so the No Suprise Law does not bring surprises to your RCM process
Recently the government did release further details of the No Surprise Billing Act. Understanding how this process will work for those payors where the anesthesia group is “out of network” is an important step for groups to begin to prepare for a change in the RCM process. There are three specific items that groups need to be considering in preparing for January 2022.
First, there will be the establishment of a federal independent dispute resolution process that will be responsible for resolving payment disputes. This goes into effect 30-Days after the filing date. The insurance company is obligated to negotiate in good faith with the group regarding a fair payment. If a fair rate cannot be agreed upon, then at the end of the thirty-day time frame any member involved may start the independent dispute resolution process. The process starts with all parties agreeing to an independent arbitrator. So start doing your research on those CMS entities who understand anesthesia and are certified (https://www.cms.gov/nosurprises). Then each party submits their offer/proposal for payment along with documentation to support their position. A $50 administrative fee will be assessed from both parties and in addition, the non-prevailing party must pay the resolution entity fee (amounts for this portion have not yet been disclosed). The decision of the arbitrator must be accepted and is considered binding, and a final payment offer.
Second, is the requirement of providing a “good faith estimate” for the uninsured. Groups should work with the facility to see if an anesthesia line item can be added to their good faith estimate for private pay patients. If not, all patients deemed as private pay will need an estimate prepared and sent in advance of surgery. Groups will have to work with their facilities to be able to identify these patients in advance and comply with providing a cost estimate for services.
Finally, the new dispute resolution process for private pay patients where the bill that they receive is “substantially” higher than the good faith estimate provided. The patient has 120 days to initiate the process. Substantially in excess is defined as $400 or more. Groups may want to establish a process similar to what we have done for years with plastic cases so they can review the actual charges versus the estimate to ensure that you will not be exceeding the $400 ceiling limit.
Change is in the air!
To view the entire Federal Register information go to: https://www.federalregister.gov/public-inspection/2021-21441/requirements-related-to-surprise-billing-part-ii.
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