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Industry Insights

How Billers Are Responding to the No Surprises Act
By: Mick Raich, President, RCM Consulting, Lighthouse Lab Services/Vachette

The No Surprises Act is now in effect as of Jan. 1, 2022. Despite efforts to inform the government of the downsides of certain aspects of this act, such as a payment dispute resolution process several provider advocacy groups are currently challenging in court, it is now law. While we’ve heard plenty of feedback from insurers and providers, billers themselves have often been left out of conversations surrounding the impacts of this new law.

In an effort to get a billing point of view, I interviewed representatives with three national billing companies to get their insight on how this will affect their business. I asked each the following questions:

  1. What is the biggest hurdle for billing companies with this new act?
  2. How will this affect your clients’ overall income?
  3. Do you feel this will increase your overall cost for billing?


What is the biggest hurdle for billing companies with this new act?

Joe Seale

Joe Seale, Director of Pathology Billing, MSN Healthcare Solutions

Joe Seale, Director of Pathology Billing at MSN Healthcare Solutions, said that while the mechanics of billing will remain mostly automated, there will be challenges in helping clients navigate the new payment dispute rules.

“Helping our clients understand the Independent Dispute Resolution (IDR) process will be the next challenge,” Seale said. “We have also made our clients aware of their responsibilities regarding Good Faith Estimates.”

Matt Zaborski, Vice President of Sales and Marketing for APS Medical Billing, agreed, adding that the rules surrounding the requirement to provide Good Faith Estimates to patients receiving out-of-network services will be an issue.

“One major hurdle for billing companies lies in provider’s requirements to provide Good Faith Estimates (GFE) prior to service being provided to the patient,” Zaborski said. “As a biller, we receive data on the back end of a patient encounter, so it is paramount that providers and healthcare systems are working together to ensure there is a process in place. We will be reliant on an electronic acknowledgement of the amount of the GFE and that it was signed by the patient.”

Lilian Garcia, CEO of Blitz Medical Billing, had another angle on this question, seeing it as two specific issues. First, she noted, “Clients are going to need to be educated on how it will affect them financially.”

Second, “Insurance companies might push more responsibility to patients, and they will have to be educated that their share of the bill might be higher than anticipated.”


How will this affect your clients’ overall income?

Matt Zaborski

Matt Zaborski, Vice President of Sales and Marketing, APS Medical Billing

As the law is currently written, Zaborski said providers’ income and profit margins are likely to decline over time.

“Carriers are required to pay their average in-network rate to out-of-network providers,” Zaborski said. “The (Biden) Administration’s interpretation of the legislation as it relates to the arbitration process seems to ignore most of the guidance and intent that professional provider groups have offered, and Providers have been told to be prepared to ‘tighten their belts’ by HHS Secretary Xavier Becerra.

“If that doesn’t provide an indication of how the scales have tilted in the payers’ favor through this Act, I’m not sure what does.”

Seale said that while most of MSN’s clients don’t stand to be significantly impacted by the new rules since they’re in network with most payers they bill, a few primarily out-of-network providers will be hit hard. However, Seale sees an option for these clients to use the Qualifying Payment Amount (QPA) to support negotiating a higher rate.

“In the case of one client, a specific large carrier’s out-of-network payment per procedure is likely to drop dramatically as the QPA is almost certainly significantly lower,” Seale explained. “Their carrier contract is significantly below the national average, and while the QPAs are regional, the new law may provide leverage through the transparency the QPA will provide to negotiate a more reasonable rate.”

Finally, Garcia said there’s no question reimbursements will decrease overall.

“There have already been in-network providers receiving letters that their in-network rates are decreasing,” Garcia said. “Since the bill requires out-of-network providers to be paid at in-network rates, reimbursement will decrease.”


Do you feel this will increase your overall cost for billing?  

Lillian Garcia

Lilian Garcia, CEO, Blitz Medical Billing

Garcia echoed what many billers are feeling as they face the challenges presented by the No Surprises Act on behalf of their clients.

“Billing will become more expensive overall to providers,” Garcia noted. “As reimbursement amounts decline, our labor costs are rising, which means we will need to increase rates to clients.

“Simply put, fighting for payment is labor intensive and our costs will increase as a result. Also, payers limit the number of claims a biller can inquire about over the phone, which means multiple calls spent waiting on hold.”

Hurdles aside, Seale sees a potential silver lining.

“In some ways, it may reduce costs and speed up collections,” Seales hypothesized. “Blue Cross Blue Shield for years has practiced the process of sending out-of-network checks and EOBs directly to the patient. With the passage of the No Surprises Act, they are barred from doing so any longer.”

Meanwhile, Zaborski thinks physician groups will have to be more active going forward.

“This new act, as with so many federal and state regulations before it, will certainly increase our cost to provide service,” Zaborski acknowledged. “Ensuring compliance with the GFE and other requirements demand costly system and process updates we must endure. Further, we foresee an influx of activity related to arbitration of payment amounts as clients’ revenue is negatively affected.”

Similar to contract negotiations, Zaborski said a client’s involvement in the arbitration process will play a large role in achieving positive outcomes.

“Carriers, and assumingly arbitrators, tend to work more in kind with the people whose revenue this is directly affecting, rather than a third party representing a physician group,” Zaborski said. “Being seen at the table will be essential.”


Next steps

In summary, the final results from the No Surprises Act are likely to cause some billing and collection issues for most providers. Like changing any process, there will be a cost as the old way of doing business is adjusted. If your lab or pathology group needs assistance interpreting these new rules and developing a gameplan for compliance, Lighthouse Lab Services and Vachette will develop a solution for you.

Feel free to contact us with your questions today!


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