No Surprises Act Update

What You Need to Know in 2023

Effective January 1, 2022, the No Surprises Act (NSA) or the Health Care Price Protection and Transparency Act established federal protections against surprise medical billing by setting a cap on out-of-network charges at the median in-network rate for a particular service. There have been several aspects of the legislation that have been changed and clarified over the past year. 

Most recently, in late December 2022, the Centers for Medicare and Medicaid Services (CMS) amended the fees for the independent dispute resolution (IDR) process by 600%. The fee increase is a result of CMS receiving a greater number of disputes than initially anticipated. Increasing from $50 to $350 per claim, providers and health plans may now reconsider appealing an underpayment from health insurance companies.

For radiology providers, the No Surprises Act could be a blessing in disguise. With the cap on out-of-network charges, imaging departments may be able to negotiate better contracts with insurance companies. This could lead to more in-network radiology providers and more competition, which could benefit patients by keeping prices lower.

At the same time, however, the No Surprises Act could also have some negative impacts on a radiology department’s bottom line. Because most radiology claims are less than $350, it would not be cost effective to request IDR. Even if the physician or department were to be successful in their appeal, the arbitration fee plus any fee assessed by the arbiter would outweigh the return. In addition, some radiology providers may be forced to lower their prices to stay competitive. This could result in lower revenues for imaging departments.

All things considered, price transparency is in both the patient and the provider’s best interests. Patients have been insisting on more detailed information regarding healthcare billing practices for a long time, and the unknown of what they may be billed for has led many to avoid medical treatment or make uninformed decisions. Providers will benefit from improved patient relations but need to take the time to fully understand the Act and how it may affect their facility.

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