The federal No Surprises Act was enacted on 28 December 2020. As per the Act, patients will be protected from the surprise medical bills that are handed over to them in case of a particular emergency as well as the non-emergency settings involving out-of-network settings.
According to the No Surprises Act, the payors will have to provide treatment to out-of-network patients considering them to be in-network. The Act mentions a procedural process through which providers and payors can arbitrate any payment disputes that are out-of-network. Other features of the process will be gradually known in the regulations that are in the pipeline.
The protections under the No Surprises Act became effective on January 1, 2022. The details are as follows.
The 30-Day Negotiation Period
After the payor responds to a provider, one month is the maximum time they can take in order to negotiate between themselves in order to resolve the dispute voluntarily if possible, before arbitration becomes the only option.
The Four-Day Period
If the provider and the payor fail to negotiate between themselves within the one-month time period, either the provider or the payor can choose arbitration. The time frame given to request arbitration is four days.
Who Is the Arbitrator?
The process of arbitration in such cases is presided over by independent entities who have experience in resolving disputes. The federal government has passed a resolution that lays emphasis on resolving disputes by independent entities. The regulation also includes a list that mentions the names of qualified entities who can be fit to provide arbitration services.
What Type of Arbitration Is It?
The basic style of arbitration that the No Surprises Act adopts is the baseball style. This specific type of arbitration is not identical to the typical process that parties usually go through while being involved in arbitration, in any way. When an arbitration process is conducted in the baseball style, each of the concerned parties offers an amount as payment to get the dispute resolved.
It’s the arbitrator’s discretion to choose either of the amounts offered. But that doesn’t lead to any other conclusion. In baseball-style arbitration, like a majority of the arbitration procedures, the decision of the arbitrator will be binding on the disputing parties. However, the parties can settle or negotiate even after the arbitration decision has been passed.
A number of cases can be put together in a batch and pushed into a single arbitration. This is done to bring in more efficiency. That being said, the cases put in a batch must have the same provider, same insurer, similar medical condition, and similar treatment. Cases that have occurred within a month can get batched together.
The Losing Party Pays the Arbitration Costs
Never has the losing party paid the arbitration costs before. That hasn’t ever been according to the normal domestic litigation and the norms of arbitration. However, Congress has surprised everyone by imposing the expenses related to the administrative costs of arbitration on the party that loses in the arbitration. It is being presumed that Congress has taken this decision so that the parties can focus on settling the disputes between them and not get involved in anything aggressive.
90-Day Lockout Period
If a party initiates the arbitration procedure, it will have to face a 90-day lockout period after the arbitration passes a decision. This implies that it can’t involve the same party in another arbitration within those 90 days. The goal is to push the disputing parties to settle an issue that has similar claims, between themselves. In case there is a claim that occurs during this 90-day time frame, it will go into arbitration after this time frame is over.
Arbitrations have the liberty to consider various factors. The factors have been mentioned in the No Surprises Act. One, the training and experience, the quality and outcomes measurements, patient acuity and complexity of services, teaching status, the scope of services, and case mix, the qualifying payments amount, the market share held, and so on and so forth.
The arbitrators can’t consider the billed charge or the usual charge as well as the public payor reimbursement rates, such as Medicare, Medicaid, TRICARE, or CHIP. providers who have OON exposure should now focus on assessing how they can approach this particular type of arbitration so that they are totally prepared after the implementation of the No Surprises Act is in full swing.