Amplifying Claim Payments under the No Surprises Act
When the No Surprises Act went into effect on January 1, 2022, it raised more questions than answers for many physicians and administrators. More often than not, healthcare leaders were left wondering how, and when, they could be affected. In fact, according to a survey from The Workgroup for Electronic Data Interchange (WEDI), eighty nine percent of medical providers relayed that it may be difficult for their convening provider or facility to identify all appropriate co-providers that there is or facilities for a specific medical service in order to provide a Good Faith Estimate. It’s clear that a learning curve exists when it comes to the No Surprises Act.
Now, as these regulations are well underway, practitioners have begun to receive payments from claims that fall under the guidelines. However, once payers started to pay the claims that were subject to these rules, many practices found that these out-of-network claims were being paid differently than in the past. Unfortunately for physicians, the rhyme or reason for these payment discrepancies is often hard to uncover. Receiving clarity on a claim that is suspected of being underpaid or denied mistakenly has always been somewhat of a struggle. Valuable time and effort is needed to dig deep into the claim, gather documentation and reach the right person at the payer level. From there it’s a waiting game that further delays collecting on what’s owed – which hurts the bottom line. Gaining the correct reimbursement on claims subjected to the No Surprises Act is easier said than done, so what best practices can providers enact in order to ensure they are being paid optimally?
First, practices need to pull out their figurative magnifying glasses. Each and every claim should be looked at in depth to ensure fair payment. Meeting the needs of the No Surprises Act can make it more difficult to identify if claims have been paid properly, so due diligence needs to be done to make sure money is not being left on the table. Practices need to devote adequate time and resources to this task.
Next, denials and contract management tools should be incorporated. Solutions and services exist that can make it easier to examine claims and remittances, taking a close look at each claim and how it’s been paid under the new qualifications. By identifying denials and underpayments, these tools can help providers know which claims to place focus on. Solutions like Advanced Reimbursement Manager (ARM) from TriZetto Provider Solutions (TPS) streamlines the discovery and recovery of denied and underpaid claims with automated technology, making it faster for the claims in question to be re-worked.
Having the right tools in place is one thing, but they are not efficient if steps are not taken to fully recover the potential lost revenue. So the last thing practices need to do is take appropriate action if it’s believed that an underpayment exists. To start, the powers that be within the practice need to determine if the reimbursement is fair in their eyes. If money has been left on the table, the option exists to appeal the claim, which needs to be filed within a 30 day period. Under established rules, an open negotiation period with the payer then begins. From there, the provider’s office would need to gather the relevant information needed to move forward with a dispute. To formalize the claim, ARM from TPS can create a letter to help state the case, which is sent to the payer. If the outcome is still unfavorable, providers can opt for an independent dispute resolution process, where a neutral, independent third party arbitrator is hired to examine the payment.
The process – and the basics of the No Surprises Act for that matter – are all very deadline and process driven. There are timelines for disputes and penalties for missed dates. This means a lot of work for providers and their office staff. With the legalities of act, most practices are learning as they go. However, don’t let the unknown hurt your reimbursements and cash flow. It’s time to consider the benefits and time-saving capabilities of automated claims management tools.
To stay up to date on the latest regulations affecting the No Surprises Act, visit the TriZetto Provider Solutions resource center.