About the No Surprises Act
The provisions of the No Surprises Act largely went into effect Jan. 1, 2022. The Act largely serves to protect patients from surprise out of network medical bills for emergency services, including air ambulance services provided by nonparticipating providers, by capping payments at what would be in-network rates.
Balance billing is generally prohibited for air ambulance services.* The total amount paid to the provider/ facility must be based on the “recognized amount,” which is (in order of priority):
- An amount determined by an applicable All-Payer Model (APM) Agreement
- An amount determined by specified state law
- An amount agreed upon by the plan/issuer and provider/facility
- An amount determined by an independent dispute resolution (IDR) entity
Likewise, patient cost is limited to the billed amount or qualifying payment amount, whichever is less. Cost sharing can never exceed the amount the amount the patient would otherwise pay if the services were rendered by a participating provider.
Qualifying Payment Amount
In a nutshell, the QPA is a single payer’s median contracted rate for the same or a similar service in a particular geographic region. As part of the initial payment or notice of denial of payment, the plan/issuer must provide the QPA for each item/service as well as a statement certifying that the QPA applies and was determined in compliance with the methodology outlined in the regulations. Upon request, they must also provide information about QPA pricing, including whether it includes non-fee-for-service rates, was based on a derived amount, which related service codes were used to price new codes, and what database was used (if relevant), and any APM-based rates that were not included in calculating the QPA. Notably, they are not required to replicate how the QPA was calculated or provide the original raw data used to calculate it.**
What are the additional circumstances that an IDR Entity shall consider?
For air ambulance service providers, the additional factors that an IDR Entity shall consider include:
- Quality and outcomes measurements of the provider that furnished such services
- Acuity of the individual receiving such services or the complexity of furnishing such services to such individual
- The training, experience, and quality of the medical personnel that furnished such service.
- Ambulance vehicle type, including the clinical capability level of such vehicle.
- Population density of the pick-up location.
- Demonstration of good faith efforts (or lack thereof) made by the non-participating provider/facility or plan/issuer to enter into in-network agreements
How the tool works
ACCT has developed the Payment Evaluation Tool to help providers accurately and transparently describe, account for, and document these capabilities and investments when submitting for reimbursement, defending a negotiated QPA and supporting provider pricing documentation if needed in an independent dispute resolution process.
Every air ambulance provider determines their scope of mission, practice, patient populations served and their geographical coverage area. These determinations translate into the necessary investment assuring safe and high quality care to the population served. As such, air ambulance providers vary significantly in clinical and aviation capabilities based on the scope of mission and the level of provider investment. These capabilities have a direct impact on the quality and safety of patient care.
In addition, the complexity of managing individual patients varies significantly, e.g. a STEMI patient with minimal interventions at bedside or during transport is a very different patient than a patient requiring complex resuscitation at the bedside and ongoing resuscitation ECMO during transport.
The PET is designed to accurately measure and document provider investment in clinical capability including patient care technology and therapeutics, clinical crew education and documented performance, aircraft and aviation capabilities, and system infrastructure in the delivery of patient care. Additionally, this tool is intended to serve as an educational resource for all parties, including payers and certified IDR entities.
The tool combines the patient care record across a step-by-step process to appropriately describe and weight baseline and additional factors that Congress included in the law for IDR entities to consider in their final reimbursement decision based on the provider’s level of investment in important areas such as clinical capability, safety, and quality of care and adjusts for low volume rural and super rural points of patient pick-up and good faith provider efforts to develop in-network agreements. The categories are weighted based on their relative degree of investment and impact on clinical capability, quality, and safety. For example, large fixed costs such as airplane type are weighted more than variable costs that depend on the patient encounter, such as patient complexity.
When you access your results, the tool will provide you with examples of supporting documentation for each category.
How does this tool fit into the larger payer-provider dispute resolution process?
This tool is intended to assist air ambulance service providers with step five below, submitting offers along with supplemental information and documentation.***
Step 1- Initial payment/notice of denial must occur within 30 days of a bill being submitted. As part of the initial payment or notice of denial of payment, the plan/issuer must provide the QPA for each item/service as well as a statement certifying that the QPA applies and was determined in compliance with the methodology outlined in the regulations, as well as additional information upon request from the provider/facility.
Step 2- Initiating the “open negotiation period”– Disputing parties have 30 business days upon receipt to initiate in writing (electronic is acceptable) an open negotiation period to negotiate a payment rate. A full 30 calendar days must run out before either party can proceed to the next step.
Step 3- Initiating the IDR process – Within four business days of the 30-day open negotiation period concluding, either party may initiate the federal IDR process by sending a notice to the other party and federal government through the federal IDR portal available at https://www.nsa-idr.cms.gov. The receiving party then has three business days to respond.
Step 4- Selecting an IDR entity – If the two parties cannot agree on an IDR entity within 3 business days, one will be selected at random within six business days. The chosen IDR entity has 3 business days to attest that they meet all requirements, including no conflicts of interest.
Step 5- Submission of offers – Once an IDR entity is selected, both parties have 10 business days to submit their offers, any required or supplemental information or documentation, a non-refundable admin fee of $50, and a certified IDR entity fee varying from $300-600 (later refundable to “prevailing” party).
Step 6- Determining a final payment amount – The certified IDR entity has 30 business days to decide and notify the parties. The decision is binding unless fraud is discovered.
Step 7- Final payment – Any resulting balance between the parties must be paid within 30 calendar days. The patient copay may not change. Within 30 business days, the prevailing party will be refunded the certified IDR entity fee. The non-prevailing party will owe an additional fee.
Step 8- “Cooling off” period – The initiating party may not start a new IDR process involving the same party & service(s) for 90 calendar days.