By Edward Marasco, MPM, CMTE, EMT-P (ret.)*



The No Surprises Act (NSA) was passed late in 2020 and the regulatory process unfolded in a frenzy throughout 2021. Providers and health plans alike have struggled to prepare for the go live date of January 1, 2022. At this time, there are still more questions than answers in the process. Some of the burning questions we have received include:

How is patient responsibility calculated and how should providers handle the billing when the claim will go to Independent Dispute Resolution (IDR)?

The NSA regulations suggest patient responsibility should be calculated using the Qualifying Payment Amount (QPA) (in-network cost sharing amount). Since the in-network rates are unique to each provider, and expressly confidential, there is no way for an individual out of network provider to verify the cost sharing amount on the EOB as correct. QMC is inquiring directly with payors as to the computation of patient responsibility; however, we have not yet received any explanation.

NSA FAQs Part II - a man sits at the desk with a laptop in front of him and his hands on his forehead

In addition, there is a school of thought that would suggest the cost sharing amount should be computed based on the ultimate payment decision issued by the IDR Entity (IDRE). If the provider bills the patient based on the initial amount on the EOB, there are both process and patient satisfaction considerations associated with billing an additional amount later. 

What are the options for claims that are considered non-NSA claims by the payor? 

In several situations, where adequate reasoning is not being provided, payors believe their plan/product is not subject to the tenets of the NSA. In these cases, the payor is not recognizing the provider’s options to initiate Open Negotiation and move to IDR. QMC is working to determine the best course of action when the payment is not adequate, and the payor does not recognize the claim as subject to NSA provisions. 

Should providers file complaints about payor behavior under the NSA?

QMC has made a number of inquiries for clarification through the NSA Help Desk process (both by telephone and by e-mail). None of these questions have been addressed thus far and some of the inquires date back to fall of 2021.

The professional associations are urging their members to file complaints through the complaint process that is permitted by the law and the associated regulations. The goal is to both get them on record with the Tri-agencies AND build a case for action (especially in situations where payor behavior is not congruent with the regulations). Unfortunately, the prescribed process is lengthy (7 to 10 pages of information must be submitted at a minimum) and the process does NOT allow for batching inquiries/complaints that represent the same issue/matter. 

The NSA remains a challenge to air medical services providers from a compliance, process, operational and financial perspective. Stay tuned right here for more information and updates as the process evolves.

*Ed Marasco is QMC’s Vice-President of Business Development and a veteran healthcare provider and administrator with over 40 years of experience in emergency medical services, reimbursement and consulting.

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