“No Surprises Act” – Impact on Radiologist

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No Surprises Act Impact on Radiologist
The No Surprises Act provides new federal
consumer protections against surprise medical
bills and it contains key protections to hold
consumers harmless from the cost of unanticipated
out-of-network medical bills. Surprise billing
can arise in both emergency and non-emergency
situations and it is observed that 2 in 3 adults
are worried about unexpected medical bills.
Moreover, when it comes to privately insured
patients, 1 in 5 emergency claims and 1 in 6
in-network hospitalizations include at least one
out-of-network bill. Hence it is necessary to
know about its implementation for every physician
and practice. Implementation of No Surprises
Act The new law takes effect on or after
January 1, 2022, for the health plan and it
applies to nearly all private health plans
offered by employers (including grandfathered
group health plans and the Federal Employees
Health Benefits Program), non-group health
insurance policies offered through and outside of
the marketplace. You can find that the effective
date is still some months away, but many
radiology groups are working to implement the
compliance as it will require a high level of
cooperation with the practices hospital.
However, the imaging centers will not be impacted
in the same way since they already are in control
of which patients come to their facility and most
likely have procedures in place to prevent an
out-of-network situation from occurring without
the patients knowledge and consent.
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No Surprises Act Impact on Radiologist
Since radiologists are prohibited from bypassing
the No Surprises Act using a consent waiver, it
is interesting to understand the impact of the
No Surprises Act on the radiologist. Impact on
Radiologists You already noticed that the act
prohibits billing the patient, hence
every radiology practice must become more
diligent about working with the hospital
registration system to obtain accurate insurance
information and the radiology practices
periodically must review all out-of-network
payments from insurance plans with which they do
not have a contract because the new law mandates
that negotiations over a disputed amount must
take place within 30 days of the receipt of
payments. It is advisable that radiology
practice should develop a schedule of minimum
acceptable amounts in advance which allow
payments at or above the minimum to be accepted
so that only those falling below the minimum are
selected for an appeal to the payor and over
time, the practice will reach a level of
agreement with most of the insurance plans for
out-of-network payments, which might even lead to
a formal participation agreement.
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No Surprises Act Impact on Radiologist
Now you have a broad level of understanding about
impacts on radiology, however, you can anticipate
these impacts if you are a radiologist and
prepare well for The No Surprises Act with the
following steps. Determine if the law applies to
your practice If you are a radiologist then the
first level of decision-making is to determine if
your practice operates in a state where the
federal law applies as The No Surprises Act
will not supersede state laws. There was no list
of such states included in the act, but the
Commonwealth Fund is an organization that has
monitored the activity of states and maintains a
database. Identify which payers are out of
network The best thing to start by developing a
list of insurance plans with which your practice
participates and compare it with a similar list
from the hospital. This comparison enables you to
identify which hospital is in-network, but your
practice is out-of-network (OON). It will also be
useful to identify plans where neither the
hospital nor the practice is in-network, as
patients with all insurance plans can be seen in
the hospital emergency department.
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No Surprises Act Impact on Radiologist
You may encounter some circumstances where it is
unclear which company is the payor due to the
insurance carrier of the patient appearing to be
out of network for the practice. However, the
patient is a member of an underlying
participating network and it is processed by the
apparent carrier. In such situations, OON claim
handling remains the same but on receipt of the
explanation of benefits (EOB), the practice would
handle it the same way as it usually would for a
participating claim. Establish the internal
process You can set your billing process to
handle charges for those OON plans in a special
way with the help of the information gathered
about the plan participation status of the
hospital and the practice. Moreover, submission
of the initial claim to the insurance company
should be at the practices full fee schedule
amount as usual. Now the billing system must be
set up to identify the claim for manual staff
review and not immediately balance-bill the
patient once the practice receives an initial
payment of the OON claim from the insurer. The
staff needs to determine if the payment is
acceptable to the practice as these accounts must
be acted upon promptly because the practice has
only 30 days to a resolution with the payor or
file a dispute if it disagrees with a payment
amount.
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No Surprises Act Impact on Radiologist
Finally, you should note that this new federal
act will not apply in states that have their own
comprehensive balance billing protection in
place. The federal law goes into effect in 2022,
so there is time to prepare your practices
workflows and policies to ensure compliance. Now
you have a clear understanding of impacts and
some preparatory measures for your radiology
practice. If you are looking to outsource your
radiology billing services so that you can focus
on your core competency then get in touch with us.