The No Surprises Act (NSA) was enacted on December 27, 2020, to address certain instances of surprise billing – circumstances where individuals with private health plans and coverage receive unexpectedly high medical bills when they are unknowingly or unavoidably treated by out-of-network (OON) providers. For decades, patients struggled with surprise billing while payers and OON providers engaged in elongated reimbursement discussions. Through the enactment of NSA, Congress aimed to reduce the numbers of consumer complaints associated with surprise billing and its consequential adverse financial impacts for patients, providers, payers, and the overall healthcare system.
To make these goals a reality, Congress created the Independent Dispute Resolution (IDR) process by which providers and payers could arbitrate payments disputes, which prevents beneficiaries from receiving surprise medical bills and furnishes a final resolution for payment disputes.
The Federal NSA IDR has three main audiences: patients, payers, and providers. For each group, IDR has resulted in positive benefits.
For patients, the NSA has been estimated to have prevented a minimum ten (10) million surprise medical bills in 2023 with an ever increasing number of surprise bills prevented each year (over 1 million per month).
Patients are held harmless from receiving OON services, particularly in emergency situations, where immediate care is most important regardless of the provider’s status with the patient’s health plan.
For providers, insurance billing disputes and unresolved payment issues can affect the financial stability of their practice and potentially impact their ability to provide quality care to patients.
For payers, strained relationships with providers impact the patient experience and divert attention from finding cost-effective healthcare outcomes.
Jointly, the NSA offers payers and providers the opportunity for cost-saving settlements and arbitrations rather than resorting to lengthy and costly legal battles.
That is where IDREs like FHAS step in to arbitrate and provide efficient, trustworthy solutions to both providers and payers, effectively reducing the strain inherent in medical insurance disputes and out-of-network payment negotiations.
The No Surprises Act (NSA) established a structured framework for resolving surprise medical billing disputes in a fair and streamlined manner.
In the public eye, the act has focused on the benefits to the patients who were historically hit with large, unexpected medical bills (referred to as balance billing) — often for medical emergencies and other out-of-network medical care at an in-network healthcare facility.
This includes a range of medical services, including emergency care, anesthesiology, pathology, radiology, neonatology, services provided by assistant surgeons, hospitalists, intensivists, diagnostic tests like radiology and lab work, as well as out-of-network care when no in-network provider is available.
This legislation now puts the onus on the physicians, medical groups, and facilities to reach an agreement with the patient’s health plan on appropriate payment for these services. This can prove challenging, as providers seek timely payment for their services while health plans strive for fair pricing based on market rates and other relevant factors.
An IDRE ensures the necessary information to make a determination is collected from both sides, and CMS guidelines are carried out for fair opportunities for both parties to participate equally in the process and make their case.
An IDRE’s effectiveness lies in its impartiality. In health insurance disputes, the IDRE must handle the case with complete neutrality and gather all the necessary material. Once this information is collected, the arbitrator reviews both sides’ perspectives to reach a fair resolution in NSA-eligible out-of-network medical insurance disputes.
FHAS stands out as a certified Independent Dispute Resolution Entity (IDRE) under the No Surprises Act, providing impartial and efficient resolution of payment disputes between healthcare providers and health insurance plans for out-of-network services.
With a focus on fair outcomes and compliance with legal requirements, FHAS ensures that both parties benefit from transparent resolutions. With years of expertise and streamlined processes, FHAS stands out for its exceptional productivity, consistently closing more disputes than received each month. FHAS is dedicated to following CMS-dictated timelines to deliver timely payment determinations.
FHAS actively enhances the effectiveness and fairness of dispute resolution by ensuring the NSA process is followed while providing feedback to CMS on a regular basis to get clarification and address gaps in the still-new process.
With an efficient end-to-end system and comprehensive approach, FHAS aims to streamline the burdensome out-of-network medical provider-payer payment disagreements, ultimately building trust and confidence in the resolution process.
Arbitration utilizing an IDRE maintains transparency throughout the dispute resolution process.
An IDRE is well-equipped to handle the nuances of various types of insurance payment disputes, ensuring resolutions are accurate and adhere to industry standards. FHAS brings years of specialized expertise to this process through arbitration, with arbitrators who possess decades of healthcare adjudication experience and training from the American Health Law Association.
Arbitration has a number of benefits for both providers and payers.
Entities like FHAS play a vital role in promoting fair and efficient arbitration processes and independent dispute resolution. FHAS has solidified a reputation for providing a neutral and impartial platform for businesses to resolve disputes.
Customers appreciate FHAS for its lower fees, ease of operation, and consistent status updates. The company’s accurate eligibility determinations, contributing to a smoother dispute resolution process, reflect its dedication to providing exceptional service and value to its customers.
By looking to arbitration, both providers and payers can contribute to a more equitable and effective healthcare system for all parties involved.
Contact us today to learn more about our IDR services.