The federal No Surprises Act became effective on January 1, 2022. This Act provides protections for patients against surprise medical bills from doctors, hospitals, and air ambulances for out-of-network emergency care and for care provided by out-of-network providers at in-network facilities.
First and foremost, the No Surprises Act requires the payer plan or issuer to either make an initial payment or send a notice of denial payment within 30 calendar days after receipt of a “clean” claim. When the payer plan issues a payment to a provider under the No Surprises Act, the EOB should be reviewed carefully to make certain that the payer plan is in compliance with the Act’s disclosure requirements. If the out-of-network provider receives an initial payment and explanation of benefits from the payer plan, make certain the EOB provides (1) the qualified payment amount (QPA), (2) a statement notifying the out-of-network provider of the option to initiate the 30-day open negotiation period to resolve a payment dispute, and (3) the payer plan’s contact information to initiate open negotiations. If the 30-day open negotiation period does not resolve in settlement, then the provider may initiate the federal Independent Dispute Resolution (IDR) process after the end of the open negotiation process.
Please make sure the payer plan’s EOB provides the required contact information, which includes the telephone number or email address of the appropriate office to initiate open negotiations. A provider who has concerns that the 30-day requirement to issue the initial payment or notice of denial has not been adhered to may contact the No Surprises Help Desk at 1-800-985-3059 or submit a complaint at https://www.cms.gov/nosurprises/policies-and-resources/providers-submit-a-billing-complaint.
Also, if the EOB is not in compliance with the Act’s disclosure requirements and regulations as set forth above, the out-of-network provider may request an extension to initiate the IDR process by emailing a request for extension due to extenuating circumstances to FederalIDRQuestions@cms.hhs.gov or may contact the No Surprises Help Desk at 1-800-985-3059 or submit a complaint at https://www.cms.gov/nosurprises/policies-and-resources/providers-submit-a-billing-complaint. It should be noted, however, that even if the payer plan fails to comply with the disclosure requirements of the No Surprises Act, the out-of-network provider can still move forward with the filing of the 30-day open negotiation period if they so choose.
Also of note, if the out-of-network provider intends to open a 30-day negotiation period, the provider must use the standard open negotiation notice form to send to the payer plan as required by the Act. If the 30th business day of the negotiation period ends without settlement, the provider may initiate the IDR process. To the extent the provider sends a timely open negotiation notice form to the payer plan and the payer plan does not respond during the 30 business day open negotiation period, the provider can still initiate the federal IDR process. The federal IDR process must be initiated within the 4 business day period commencing on the 31st business day after the start of the open negotiation period. So even if the payer plan does not respond to the open period negotiation request, after day 30, the provider can still proceed to the next step, which is the Independent Dispute Resolution process.
This article includes excerpts from the August 19, 2022 CMS FAQs from the US Departments of Health and Human Services, Labor, and the Treasury regarding the final rules under the federal No Surprises Act. If you have any questions about the federal No Surprises Act or any other questions regarding healthcare reimbursement, please feel free to contact Attorney Charles J. Hilton at 412/435-0162 or email at chilton@cjhiltonlaw.com.
Law Firm of Charles J. Hilton & Associates, P.C.
Attorneys at Law
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(412) 435-0162
Email :chilton@cjhiltonlaw.com