Claims Adjudication

HHS: Insurers won’t be penalized if they don’t update their No Surprises Act qualifying payment amounts as required

Providers may not immediately benefit from a favorable court ruling that affects the methodology for determining the qualifying payment amount (QPA) under the No Surprises Act. The U.S. Department of Health and Human Services (HHS) issued guidance Oct. 6 that says the Biden administration will not enforce the court decision until at least May 1.…

Nick Hut October 9, 2023

HHS sets new administrative fee to be paid by parties in No Surprises Act independent dispute resolution cases

Oct. 6 update: The lead section of this article was updated where noted with news about the arbitration portal. The administrative fee for taking out-of-network payment disputes to arbitration under the No Surprises Act in 2024 would be significantly lower than it was for much of 2023, but triple the current rate, according to proposed…

Nick Hut September 22, 2023

No Surprises Act litigation update: QPA methodology deemed illegal as Texas Medical Association wins in court again (updated)

Note: The first section of this article has been updated with the latest news on the status of the arbitration portal. The fourth victory in four cases brought by the Texas Medical Association (TMA) has implications for how insurers calculate the qualifying payment amount (QPA) used to arbitrate out-of-network payment sums under the No Surprises…

Nick Hut August 25, 2023

Healthcare News of Note: DOL sues UnitedHealth Group subsidiary for claim denials

The U.S. Department of Labor recently sued UMR Inc., the nation’s largest third-party healthcare claims administrator, for denials involving emergency department services and urinary drug screening. Twenty-two of U.S. News & World Report’s Best Hospitals also made the publication’s honor roll, which recognizes hospitals for demonstrating exceptional breadth of excellence across clinical specialties. Substantial resources…

Deborah Filipek August 18, 2023

House committee approves bill requiring national provider identifiers for off-campus outpatient departments

A bill with widespread support in Congress would affect hospital billing procedures at off-campus outpatient departments if it becomes law. The House Committee on Education and the Workforce on July 12 unanimously approved legislation called the Transparency in Billing Act, which states that starting in 2024, hospital claims for items and services furnished in off-campus…

Nick Hut July 19, 2023

Report quantifies the financial impact of certain health plan business practices on providers

As hospitals seek to regain their financial footing coming out of the pandemic, they may find themselves stymied by commercial payer policies, according to a new report. “It’s true that commercial payers might generate more net revenue than public payers on a per-case basis,” Crowe states in a report it recently published. “But at what…

Nick Hut June 2, 2023

How healthcare organizations navigate claims processing

View the results of a survey about claims processing and revenue cycle performance conducted with more than 625 healthcare leaders.

HFMA May 30, 2023

The impact of claims denials on the financial health of healthcare

While their hospitals and healthcare centers have long had to deal with claims denials, the number of denied claims continues to rise and payers are showing little inclination to help solve the problem, according to several roundtable participants.

HFMA March 29, 2023

For the No Surprises Act arbitration process, 2023 brings a steep fee hike and continuing litigation

The No Surprises Act’s independent dispute resolution (IDR) process is about to become more expensive for healthcare stakeholders. In 2023, the nonrefundable administrative fee due from each party involved in any payment dispute that goes to arbitration will increase from $50 to $350, according to a Dec. 23 memo from CMS’s Center for Consumer Information and Insurance…

Nick Hut December 30, 2022

Clinical audits and denials impact 3% or more of NPR being held in reserve

This pulse survey shows how healthcare organizations are currently tracking health system’s audits and denials from government and commercial payers.

Jennifer Novoseletsky December 1, 2022
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