Navigating the changes to revenue and billing practices in the No Surprises Act
Billing in healthcare can be extremely complicated, especially when trying to get all the stakeholders on the same page. New legislation, in the form of the No Surprises Act, introduces a new web to untangle for those involved in handling billing for out-of-network care for patients.
Often, in the course of seeking and receiving medical care, patients find themselves in a situation where one or more of the services provided comes from a provider who does not have an in-network business relationship with the patient’s insurance network. Through no fault of their own, patients are billed for a service that is not adequately covered by their insurance. The No Surprises Act, which went into effect Jan. 1, 2022, aims to protect patients from the financial burden of this out-of-network care. In this roundtable, sponsored by Olive, revenue cycle leaders discuss the anticipated challenges arising from the new legislation and their strategies for approaching these challenges.
Shawn Stack: What potential areas of concern or exposure come to mind with respect to your current payer contracts for regulations for emergency services under No Surprises? What do you see as your largest impacts with emergency services?
Mike Sims: We’ll have patients coming in [with insurance from payers] whom we don’t have a contract with, in regards to balance billing under the new legislation. Our hands are tied with that emergency. It’s very important for us to educate these out-of-network patients so they continue to come to our facility. Also, currently, out-of-network patients will receive checks from payers, but they’re not sending the payment to us. With the legislation change, that stops; the payer is now supposed to remit that payment to us. The main issue is going to be accepting out-of-network rates in the ER.
Stack: Do you think this will encourage that more contracts should be built with providers?
Aren Laljie: I think it’s the opposite. You have a patient who shows up in the emergency room. Now they have to go through a complex process under the legislation to determine the payment for service. You really can’t pick it apart anymore. It’s hard to balance that process. With out-of-network patients, we don’t know what rate to expect. Payers don’t need to contract with providers anymore. If there is a dispute, you have to go to arbitration, and the arbitrator decides who gets paid and how much.
Sims: It doesn’t give us leverage anymore. In contract negotiations, if we say, “We don’t like your rates,” payers can cancel their contract and continue to be out-of-network.
Laljie: They can also steer their patients away. If we are having difficulty analyzing and interpreting this, how do we expect patients to make an educated decision regarding where to go for care?
BradLey Becker: Washington state passed similar legislation back in January 2020. With one payer, we were able to leverage being in-network and had their products added through the Department of Insurance. Without our primary care network, this payer would have had an inadequate network and could have been forced to leave the county — and their several thousand patients. By controlling the primary care network, we were able to get an expanded contract with that payer.
Olive Product Manager: The state of Texas also passed this legislation four years ago, and we had to react. Given that your state did as well, were you able to achieve notifying patients in real time that they’re out-of-network, whether at the time of scheduling or registration?
Becker: We are a critical access hospital with rural health clinics, and we’re in the process of consolidating eight of those clinics into one building. That took the significant focus of our organization, and we had challenges implementing solutions for that aspect of compliance. Fortunately, addressing this one significant contract resolved that issue.
Angela Shelton: Has anyone else achieved that real-time identification?
Kristen Bates: In the ED, we put an icon on the bed board for ‘out of network’ to notify the caregivers so that they can have that conversation with the patients. It’s been a challenge to have the caregivers understand that their responsibility is not just the care of the patient but also financial care.
We also created a training that we’re rolling out to our employees throughout UH to understand the law, and also understand their role in it, so that it doesn’t all fall on revenue cycle. It’s a shared effort among us all.
Shelton: If you have a large health plan that has a lot of volume that is out of network, you can identify those patients relatively easily. We are in network with almost all the large payers. How do you build your system to identify that small out-of-network population?
Bates: The idea is, if they’re going to be admitted or if they need further care, to help them understand that there are better places for them to get it from a financial standpoint. If they’re out of network for a facility, we could refer them to somebody else. If they’re going to be admitted and it’s not something that’s urgent, we communicate that and transfer the patient to an in-network facility.
Marsha Morien: How are we educating patients about this change? It would be an extraordinarily difficult time to have the patient’s family listening to you as part of an emergency visit.
Shelton: We don’t currently have a good process to identify out-of-network patients during an emergency encounter. Right now, we bill the out-of-network payer as usual and will often see a request for a single case agreement from the smaller insurance company retroactively. If we had better notification abilities, we might be able to move this process closer to the front instead of dealing with it in the back end.
Sims: Regarding communication, we are running data on the out-of-network patients we’ve seen at Blue Cross. We are notifying them that they are not in network at this facility and that they will have better benefits at a different facility.
Stack: What are your payers and health plans saying about this regulation? Should you have those conversations with your payers now?
Shelton: A difficult part of that is you’d really need to have conversations with the out-of-network insurance companies, and they’re often out-of-network because we don’t have good communication with them. Ideally we would be in network with all payers.
Sims: We do reference-based pricing right now, and we balance bill patients. But in the legislation, it says reference-based pricing is not out-of-network. That’s another issue, along with Christian-ministry fundraising. They hardly pay anything.
Stack: Reference-based billing, Christian ministry fundraising, liability patients and workers’ comp patients are all considered self-pay. Those are not included in the first IFR. Those patients fall under the legislation in effect Jan. 1, 2022. Right now, your biggest concern is the patients who are uninsured or considered self-pay.
Bradley Gallaher: Also, how do we communicate with communities, especially in geographically dense areas where there are a lot of healthcare options available? Getting the patient to the best option is important. Is there another shoe that’s going to drop regarding uncompensated care, charity benefit and community benefit? If we’re lowering the average reimbursable rate, we could see a major hit on how much organizations are able to demonstrate they’re providing to their communities.
Stack: Have you thought through the impacts to prompt-pay, self-pay and charity care discounts? When your teams began providing Good Faith Estimates on Jan. 1, they were required to include in that Good Faith Estimate all applicable discounts. Is it feasible to screen all consumers for charity care prior to giving that detailed Good Faith Estimate or do disclaimers need to be provided stating that a full screening could reveal additional discounts? That’s a heavy lift.
I’m doing office hours with HFMA every other week, and callers ask questions about the new regulations, and we answer them. Then, we submit those questions to CMS. One of my question to CMS was, ‘Are worker’s comp patients and other liability patients off the hook as self-pay?’ They have a group health plan, so we bill the insurer, not the patient. Overall, the biggest challenge is the advanced EOB — the patient education piece.
Another challenge is communicating with the insurers who are the biggest offenders. I don’t think hospitals have been perfect, but CMS is not addressing at least 60% of the surprise billing issues. A lot of the issues are stimulated from payers, and they have kicked the can down the road another six months. They aren’t educating their members. They’re signing their members up for plans, but the members don’t know what is covered. If employers were more engaged, this issue wouldn’t be quite as bad as it is now.
I know it’s hard for some of you. It was for me, and I know it’s hard for UH. However, there have been hospitals at a state association level that have done an amazing job forming relationships with large local employers to help them with their big group plans. The key is patient education and employer education — trying to stay ahead of the curve and work with CMS regarding what can happen and creating solutions that work.
What do you think you can introduce to your workflows to help guide this, to make the implementation of this policy and these regulations easier? What can you do to realistically get ahead of this process?
Gallaher: One direct question to make sense of is, ‘What is the tip of the spear, and why is it so hard?’ Is it the data? Is it the changing payer plan mappings within EMR?
Sims: Epic is putting together some workflow that will assist, but it looks complicated. Your IT department has other things they’re working on. Do you think we’ll be able to get that implemented? Epic has already thought about it and will be making refinements. But it’s really scary.
Leah Klinke: The eligibility piece is hard. In Epic, you use your RTE [Real Time Eligibility] to help the plan creation. What are the flags in that eligibility response to signify that a patient is out of network? It’s different for each payer and not every payer is giving the electronic eligibility. I feel like that is a gap. To set up out-of-network plans for these patients, you have to build them and then have triggers and education to know when to select them.
The other data gap I see is that every payer is using different permit codes. If you could identify on the back end which ones are being denied because they’re out of network, you could mitigate that risk. How do we identify which accounts to review? If payers use a particular remit code, we would have more data to identify who are the worst payers.
Sims: We drive that based on our out-of-network plans. So we know from the beginning.
Olive Product Manager: Are you hydrating the 271 [Health Care Eligibility Benefit Inquiries] so that you can parse that indicator out? That’s the model I’m familiar with as well.
Sims: From a vendor perspective, this is a wonderful legislation. How many vendors are going to be able to support providers on denials? Vendors need to start marketing the arbitration process. We’re not going to be able to handle the volume.
Gallaher: There’s an interest rate that gets reimbursed to patients. I’m not clear if that applies to overpayment, purely what’s billed.
Stack: The rate is not published. My understanding is the rate is based on the amount overpaid.
In arbitration, you pay administrative fees, and the loser pays the other fee: $50 per arbitration. It is possible that you can arbitrate matches. If it’s one payer and the same issue, you can take multiples in arbitration. There’s still guidance we need to put out.
Sims: We need to point out confusion, publicly, where we don’t understand. If you’re penalized in arbitration, you can take it up through an administrative judge later. They’re reasonable people and will take into consideration that you asked for clarification in good faith. Create a written record that there was a misunderstanding.
HFMA Executive Roundtable Panelists
OLIVE PRODUCT MANAGER
Manager of coding at University Hospitals in Cleveland, Ohio
Senior director revenue cycle, Mason General Hospital & Family of Clinics in Bellingham, Wash.
Senior vice president, customer expansion, Olive in Columbus, Ohio
Assistant vice president of revenue cycle, WVU Medicine at West Virginia University Health System in Morgantown, W.Va.
CFO, Miami Children’s Health Plan in Miami
Professor emeritus for University of Nebraska Medical Center in Omaha, Neb.
Chief revenue cycle officer, Hughston Clinic in Columbus, Ga.
Vice president revenue cycle, Cone Health in Greensboro, N.C.
Director, perspectives & analysis at HFMA in Washington, D.C.
Olive is the automation company creating the Internet of Healthcare. The company is addressing healthcare’s most burdensome issues through automation — delivering hospitals, health systems and payers increased revenue, reduced costs and increased capacity. People feel lost in the system today, and healthcare employees are essentially working in the dark due to outdated technology that creates a lack of shared knowledge and siloed data. Olive is driving connections to shine new light on healthcare processes, improving operations today so everyone can benefit from a healthier industry tomorrow. To learn more about Olive, visit oliveai.com.
This published piece is provided solely for informational purposes. HFMA does not endorse the published material or warrant or guarantee its accuracy. The statements and opinions by participants are those of the participants and not those of HFMA. References to commercial manufacturers, vendors, products, or services that may appear do not constitute endorsements by HFMA.