No Surprises Act (NSA) & Reference-Based Pricing

VDHP designs incorporate features that meet requirements of the No Surprises Act (NSA) throughout a claim’s life cycle.

No Surprises Act (NSA) & Reference-Based Pricing

VDHP designs incorporate features that meet requirements of the No Surprises Act (NSA) throughout a claim’s life cycle.

Our Surprise Billing Services

Identify Surprise Bills

To help you comply with No Surprises Act (NSA) requirements, we examine billing codes and, where applicable, participating facility status.

Calculate and Append the QPA

We calculate the Qualifying Payment Amount (QPA) using MultiPlan’s practitioner and ancillary network rates, if applicable, and return the QPA on the processed claim so that your plan administrator can complete the adjudication.

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Price and Edit the Claim

The No Surprises Act (NSA) does not dictate how claims can be paid, only that members can’t be balance billed. Using our next-gen RBP technology, we will continue to reprice claims using reference-based pricing as we do today.

Negotiate Settlement

If a provider rejects the initial payment, HST’s Patient Advocacy Center will work to negotiate a settlement. With our average 98% acceptance rate, we are confident we will help you and the provider come to a mutually beneficial solution.

Arbitration

When a settlement isn’t reached, we’ll leverage the services of MultiPlan to own the Independent Dispute Resolution process from start to finish including analysis, offer and support.

Get a head start with NSA compliance

Plans using reference-based pricing with or without a network are subject to the requirements of the No Surprises Act. HST’s Value-Driven Health Plans have you covered throughout the life cycle of a claim, from identifying surprise bill claims to determining the qualifying payment amount for HST pricing and, if applicable, negotiating settlements to avoid arbitration.

FAQs

Yes. The Interim Final Rule published in July 2021 mentions indemnity plans with no facility network and acknowledges the No Surprises Act limits surprise bill protections to emergency and air ambulance claims. This is because there is no such condition as an out-of-network provider at an in-network facility if there are no facilities in network. However, agreements made between the Reference-Based Pricer and facilities apply for purposes of identifying surprise bills.

For payors, the No Surprises Act (NSA) is a complex piece of legislation to navigate as they are required to:

  • Identify out-of-network claims that are determined to be surprise bills under the law’s definition
  • Calculate the Qualifying Payment Amount and the Recognized Amount (RA) for ERISA plans as well as fully insured plans without applicable state protections.
  • Ensure plan member cost sharing is based on the RA and in-network benefits
  • Determine out-of-network rate to the provider based on an initial payment, or negotiation should that payment not be acceptable
  • Participate in an independent dispute resolution process should negotiation not lead to settlement and should the provider invoke IDR

PLEASE NOTE The information provided on this website does not, and is not intended to, constitute legal advice; instead, all information, content, and materials available on this site are for general informational purposes only.  If you have questions about the No Surprises Act, please consult your legal counsel.

New requirements begin in January 2022

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