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

With or without a practitioner network, plans using reference-based pricing are subject to the No Surprises Act. HST’s Value-Driven Health Plan services have you covered with services that meet the requirements through the claim’s lifecycle built into the plan through the negotiation process.

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.

Fichier 22

Price Claim

The No Surprises Act (NSA) does not dictate how claims can be paid, only that members can’t be balance billed. We can price the claim as normal for HST or price to QPA.

Negotiate Settlement

If a provider rejects the initial payment, HST’s Patient Advocacy Center will follow the NSA process to negotiate a settlement.

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. (This service is not included but available for a separate fee.)

FAQs

Yes. The Interim Final Rule (IFR) published in July 2021 and a FAQ published with the August 19, 2022 Final Rule made clear that the No Surprises Act applies to claims that don’t use a network. The requirements are primarily limited to emergency services and air ambulance services for health plans that do not use a provider network, or that use a partial network (e.g., providers only, but no facilities). However, the IFR also stated that agreements between the RBP vendor and a facility would have to be considered as an “in network” facility for purposes of identifying surprise bills. The FAQ further clarifies that these plans are expected to use the QPA as required under the NSA – to determine the member’s cost sharing and as disclosure to the provider with reimbursement. The departments direct these plans to use an eligible database to calculate QPA.

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 began in January 2022