Implemented in January 2022, the No Surprises Act aims to protect patients from surprise medical bills received from out-of-network (OON) providers by establishing regulations that determine reimbursement rates for qualified services and limited patient financial responsibility to in-network deductibles and out-of-pocket maximums. Additionally, the regulation introduced a dispute resolution process for uninsured and self-pay patients.
However, providers have faced operational and financial challenges due to the new requirements. Compliance with the law has necessitated changes in processes, increased administrative burdens, and increased the need for additional resources and staff training. Providers have had to adjust their revenue forecast and reconsider their participation status with health plans from the regulation limiting providers’ ability to collect balance bills from patients.
Despite the challenges, the No Surprises Act has presented opportunities for providers. Becoming an in-network provider has allowed them to improve operational efficiency by reducing administrative burdens and minimizing patient complaints related to billing. It has enhanced the patient’s experience, as being in-network increases patient volume, expands the provider referral network and improves revenue forecasting accuracy through expected reimbursement amounts. By embracing these opportunities, providers can enhance their financial sustainability and overall performance.
While there are many items to consider in complying and optimizing efficiencies with the No Surprises Act, there are many initiatives providers can take to overcome some common challenges.
Providers can focus on their payer inventory by carefully reviewing their existing payer contracts and considering expanding their in-network participation status with other health plans. By diversifying their participation, providers can increase their patient volume and reach a wider audience.
Additionally, expanding the referral network is crucial for providers to attract new patients and enhance their business. By actively seeking participation with additional health plans, providers can establish connections with more referring physicians and specialists, leading to a steady stream of referrals and increased patient traffic.
By strategically managing their payer inventory and expanding their in-network participation status, providers can effectively navigate the challenges posed by the No Surprises Act and position themselves for growth and success in the evolving healthcare landscape.
Providers can focus on developing and fostering relationships with key health plans. By proactively engaging with health plans, providers can gain a better understanding of the plan's requirements, policies and processes, which can help them navigate the complexities of billing and reimbursement.
Building strong relationships with health plans can also facilitate effective communication and collaboration when it comes to resolving disputes or addressing any issues that may arise. Providers who invest time and effort in cultivating these relationships are more likely to receive timely and accurate information, streamline administrative processes and ultimately improve their operational efficiencies.
Furthermore, maintaining positive relationships with health plans can also position providers as valuable partners, leading to potential negotiation opportunities for better contract terms, reimbursement rates and in-network status, which can positively impact their financial sustainability.
Hospital-based providers, like anesthesiologists, radiologists, pathologists and emergency providers, are encouraged to reevaluate their decision to remain as OON providers with health plans, given the potential impact of the NSA on operational efficiency and financial sustainability. Conducting a revenue analysis comparing the effects of staying OON versus becoming an INN provider is advisable, focusing on the NSA's influence on balance billing limitations.
By becoming participating providers with multiple health plans, these providers can enhance operational efficiency by reducing administrative burdens, including fewer claims appeals and reconsiderations, streamlined billing and collection processes, and a reduction in OON authorizations. This approach is crucial in minimizing patient complaints and grievances regarding billing, thereby significantly improving patient satisfaction.
From a financial perspective, rethinking in-network participation status offers numerous opportunities, such as increased patient volume, expanded provider referral networks, enhanced revenue through point-of-service coinsurance collections and more accurate revenue forecasting by knowing the expected reimbursement amount as an INN provider. Overall, the shift to INN status presents favorable prospects for both the providers and the patients they serve.
Providers can conduct a comprehensive operational review of their practice. This review should focus on streamlining and implementing processes that align with the law, ensuring compliance and minimizing potential issues.
By conducting an operational review, providers can identify any gaps or areas of improvement in their current processes, such as billing, claims appeal, authorization procedures and patient complaint management. This enables them to make necessary adjustments and implement efficient workflows that are in line with the requirements of the No Surprises Act.
Additionally, an operational review can help providers proactively address potential challenges, improve overall operational efficiencies, reduce administrative burdens and ensure smooth adherence to the components of the regulation. It is a proactive step that allows providers to be well-prepared and compliant with the law ultimately contributing to their financial sustainability and patient satisfaction.
Providers should implement a robust revenue and claims reconciliation process. This process allows them to accurately determine and understand the expected reimbursement for services provided to in-network patients.
By implementing a thorough reconciliation process, providers can identify any discrepancies between expected reimbursement and actual payments received from health plans. This helps them proactively address any underpayments or denials, reducing financial risks and ensuring proper revenue recognition.
Furthermore, a well-defined reconciliation process enables providers to track and analyze payment trends, identify any potential billing or coding errors, and make necessary adjustments to optimize their revenue cycle management. It also facilitates accurate revenue forecasting and financial planning, supporting the long-term financial sustainability of the practice in the changing healthcare landscape influenced by the law.
Providers should implement processes to provide health plans with regular updates and changes to their practice, such as demographics. This proactive approach ensures that health plans have up-to-date information, minimizing potential billing and reimbursement issues.
By regularly communicating updates and changes to health plans, providers can maintain accurate provider directories and avoid disruptions in patient access to care. This helps prevent potential out-of-network surprises for patients and reduces the likelihood of disputed claims or reimbursement delays.
Implementing streamlined processes for updating health plans also demonstrates a commitment to transparency and compliance with regulatory requirements, fostering positive relationships with health plans and supporting the provider's reputation as a reliable and trusted healthcare provider.
Providers should conduct a thorough resource assessment to determine the necessary resources required for compliance. This assessment involves evaluating staffing levels, technological capabilities, training needs and financial resources to meet the demands of the regulation.
By assessing resources, providers can identify any gaps or areas that require enhancement to ensure smooth compliance with the No Surprises Act requirements. This may involve hiring additional staff, implementing or upgrading technology systems, investing in training programs or allocating financial resources for necessary infrastructure improvements.
Taking a proactive approach to resource assessment enables providers to allocate resources effectively, plan for any necessary investments or adjustments, and ensure they have the capabilities and capacity to meet the compliance demands of the law. This positions them for successful implementation of the regulations while maintaining operational efficiencies and financial sustainability.
Providers can employ several strategies to mitigate challenges related to the No Surprises Act. These strategies include focusing on payer inventory by expanding in-network participation, developing strong relationships with health plans, conducting operational reviews, implementing revenue reconciliation processes, regularly updating health plans and conducting resource assessments. By adopting these strategies, providers can navigate the complexities of the law, optimize operational efficiency, ensure compliance and enhance financial sustainability in the evolving healthcare landscape.