Knowledge Center

The Emergency Department Practice Management Associations (EDPMA) recently published the results of their study that highlights a number of issues impacting ED Physicians Reimbursements since the implementation of the No Surprises Act (NSA), January 2022. Based on 14,500 claims reviewed in the study, from January – May 2022 from 59 practices, the report identifies, among other factors, health plan compliance issues in connection with the implementation rules issued by the Federal Departments of Health and Human Services (HHS), Labor and Treasury.

A notable finding from the study reveals:

• “91% of the claims surveyed did not include an identified qualifying payment amount (QPA) as specifically required by law”.

Consistent with our own experience handling claims for out-of-network surgeons, claims processed by the insurance companies are not being properly identified as subject to the NSA. Medical Billing departments handling claims reimbursement, in particular those reviewing explanation of benefits (EOBs) after initial payment should be aware that the information on the EOB is not always accurate and cannot be relied upon. Furthermore, many of the billing software used by out-of-network providers have yet to be updated to identify the remark codes used for NSA reporting. Often there are discrepancies between the electronic ERAs and the physical EOB.

To preserve providers’ right to dispute payment, it is critical for those handling claims to review, question and develop strategies for pursuing reimbursement under the NSA while complying with the timeliness and labor-intensive process for the independent dispute resolution process (IDR).

The guidance and implementation of the rules has been wrought with challenges adding more complexity to an already onerous process for getting paid. Without a complete understanding of the administrative requirements under the NSA to seek reimbursement and a consistent process for handling out-of-network claims, providers will continue to face challenges under the NSA.

Our company is structured to leverage our team’s broad range of medical billing, insurance and regulatory expertise to successfully devise strategies on a claim-by-claim basis in addition to having the resources to apply the consistent and persistent follow up necessary to maximize reimbursements under a complex and ever-changing set of rules.

If your practice is facing challenges under the new NSA environment in out-of-network claim revenue, please contact our offices to discuss how we can help. You can choose CH Revenue Management Solutions (CHRMS) to handle your reimbursements from the start or partner with us for your practice’s specific needs at any stage of the claims management process.