Providers Have Options for Maximizing Revenue Under the No Surprises Act

More than three years after taking effect on January 1, 2022, the No Surprises Act (NSA) is still creating waves across the healthcare industry. Specifically, the independent dispute resolution (IDR) process continues to be challenged in the courts. Moreover, provider advocacy groups report high rates of failure by insurers to pay NSA independent dispute resolution determinations (22%) and on time (35%),i creating a strong incentive to avoid IDR in the first place.

Though implementation of the NSA has been flawed and notoriously complex, providers must nevertheless comply with it. Their primary objective should be to bill accurately and compliantly to submit a clean claim and receive the maximum allowable reimbursement without delay.

Under the NSA, patients covered by group and individual health plans are protected from receiving surprise medical bills for most emergency services, non-emergency services from out-of-network providers at in-network facilities, and services from out-of-network air ambulance service providers.

Know the Rules for Compliant Patient Billing

Under the NSA, patients must not be balance billed. This highlights the need for hospitals to capture complete, accurate insurance information for the patient up front, whenever possible, and to share it with non-employee providers who are practicing in the hospital. Provider practices must have the patient’s insurance coverage and plan details to submit a clean claim to the payer under the NSA requirements and to bill the patient compliantly for their portion of the financial responsibility.

Surprise billing restrictions include:

• Banning surprise billing for emergency services (essentially qualifying all emergency departments as “in-network”)

• Eliminating high, out-of-network cost sharing for emergency and non-emergency services (co-insurance or deductibles cannot be higher than if the services were provided in-network)

• Abolishing out-of-network balance billing for ancillary care at an in-network facility

• Prohibiting out-of-network balance billing for other services without advance notice and the patient's written consent

Know the Rules for Compliant Patient Billing

Under the NSA, patients must not be balance billed. This highlights the need for hospitals to capture complete, accurate insurance information for the patient up front, whenever possible, and to share it with non-employee providers who are practicing in the hospital. Provider practices must have the patient’s insurance coverage and plan details to submit a clean claim to the payer under the NSA requirements and to bill the patient compliantly for their portion of the financial responsibility.

Arm Your RCM Team With These Secret Weapons

Any healthcare practice can benefit from automated revenue cycle management optimization tools like demographic verification, insurance discovery, and insurance verification technology. When run as early in the patient encounter as possible as part of the pre-billing process, these impressive tools can effectively capture complete, accurate primary, secondary, and tertiary coverage information, including plan details, for each patient. They can even help identify retroactive Medicaid eligibility.

Industry-leading solutions can automatically find, correct, and verify patient and payer information to capture more revenue, reduce administrative burden, and improve the patient's financial experience, too.

A billing process enhanced by RCM optimization tools should look something like this:

• Run automated demographic verification, insurance discovery, and insurance verification technology at the point of registration — or as soon as the patient’s file enters your billing system — to enhance and correct data in real time.
• Submit a claim to the payer at the full fee schedule amount if your practice treats a patient whose insurance plan considers you out-of-network.
• Critical: when reimbursement is received from the payer, flag the claim to prevent automatically balance billing the patient. Billing staff first must evaluate whether the payer reimbursement is acceptable.
  • If it is not, the practice has 30 days to come to an agreement with the payer or dispute the payment amount.
  • The independent dispute resolution (IDR) process must be used in cases where an agreement on payment amount cannot be reached between the practice and the payer.
• Bill the patient for co-payment, co-insurance, or deductible as applicable based on the insurance verification process or as informed by the explanation of benefits from the patient’s plan.
• Consider adding other RCM optimization tools, such as a self-pay analyzer and retroactive Medicaid monitoring. Both are invaluable for determining the patient’s propensity to pay and eligibility for charitable discounting. These tools are very effective for improving collections on the patient-responsible portion of the bill and increasing patient satisfaction.

ⁱAmericans for Fair Health Care. No Surprises Act (NSA) Impact Analysis 2024, https://www.americansforfairhealthcare.org/_files/ugd/11639b_5fe6eca596854e028d0d45b94d8a7b22.pdf. Accessed 16 April 2025.