Month: August 2021

Background: Federal law is required to prevent “surprise” billing

In 2020, Congress held meetings to determine whether laws should be enacted to prevent the devastating financial obligations imposed on a patient with healthcare insurance who is treated by an out-of-network provider, particularly when the patient did not know or expect that insurance coverage would be limited for that care.

During Congressional hearings, citizens recounted unexpected, and devastating, financial obligations incurred by patients who were transported by out-of-network air ambulance services. According to the Nebraska Department of Insurance, the average air ambulance trip is 52 miles and costs between $12,000 to $25,000 per flight. Since most air ambulance services do not participate as “network” providers with insurers, that portion of the bill that the insurer will not cover becomes a patient liability. The plight of these patients and others convinced Congress that federal law should prevent a “surprise” bill resulting from an uninformed patient owing large sums of money to an out-of-network provider.

“No Surprises Act” is added to the Consolidated Appropriations Act of 2021

The resulting legislation, the “No Surprises Act”, was incorporated into the Consolidated Appropriations Act of 2021, which was signed into law by then-President Trump in late December 2020. The new Federal law limits the ability of both insurers and out-of-network providers to shift a significant financial obligation to the patient/beneficiary, unless that patient is provided with advance written notice of the anticipated amount that the patient will owe, along with information about the patient’s alternatives to out-of-network care. If there is a State law that addresses the same concern, State law takes precedence.

Interim Final Rule recently released

The new law becomes effective on January 1, 2022, and the Office of Personnel Management, along with the Department of Health and Human Services, Labor, and Treasury developed implementing regulations. The first regulations, dubbed “Part 1”, were released on July 1, 2021 in an “Interim Final Rule with Comment Period” (CMS-9909-IFC.)
Stakeholders should pay particular attention to provider obligations arising from the law, including:

• Distributing standard information about patient rights under the No Surprises Act Information must be posted on the provider website, in signage in public areas of the facility, and in a written one-page, double-sided document distributed to insured patients prior to collecting payment from the patient or submitting a claim to the patient’s group health insurer. (A model notice is under development.)
• The “Notice and Consent” requirements of No Surprises Act Out-of-network providers and facilities must obtain the patient’s informed consent to collect out-of-network costs from the patient. The notice requirements include an estimate of the costs the patient will be liable to pay and information about in-network service alternatives. Notices must be available in the 15 most common languages spoken in the provider’s region. (It is not clear whether a provider may simply opt-out of the notice requirement and accept whatever the insurer’s discounted payment rate may be.)
• The method insurer must use to calculate the “Qualifying Payment Amount” for out-of-network services The payment the insurer is obligated to use in calculating provider reimbursement and patient liability for services at an out-of-network provider could be based on that insurer’s median in-network contracted rates with other like providers within the same region, depending on specific circumstances

The second set of implementing regulations, “Part 2”, are expected to be published in coming months relating to dispute resolution and other provisions of the new law.

Additional Resources

To learn more about the No Surprises Act and the regulations implementing the new law, visit the following websites:

• Interim Final Rule, CMS-9909-IFC, published on7-13-21 in the Federal Register
  • Subpart E – Health Care Provider, Health Care Facility, and Air Ambulance Service Provider Requirements
    • 149.410 Balance billing in cases of emergency services.
    • 149.420 Balance billing in cases of non-emergency services performed by nonparticipating providers at certain participating health care facilities.
    • 149.430 Provider and facility disclosure requirements regarding patient protections against balance billing.
    • 149.440 Balance billing in cases of air ambulance services.
    • 149.450 Complaints process for balance billing regarding providers and facilities.
• CMS: “Fact Sheet” on the interim final rule
• The American Hospital Association: concise summary and analysis
• The American Medical Association: high-level summary
• United Healthcare: convenient FAQ-style resource on its website
• No Surprises Campaign (People against Unfair Medical Bills): consumer stories and letters from diverse interests participating in the development of the No Surprises Act

ParaRev can help

An essential component of the “No Surprises Act” is the ability for the provider to deliver pricing transparency to the consumer. Meeting the challenges of pricing transparency demands a systematic approach grounded in empirical evidence and a capable staff implementing proven solutions. ParaRev, a leader in accounts receivable recovery and resolution, can help you execute all steps necessary to comply with the transparency rule and improve patient satisfaction. To see how this solution would work for your hospital, click here to view a short demo.

Contact us today to learn more about how we can help your organization prepare for the pricing transparency requirement that is a critical component of the “No Surprises Act”.

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A health insurance company as prominent as Blue Cross Blue Shield (BCBS), having over 62 million members across all 50 states, provides high potential for revenue generating opportunities for any hospital Central Billing Office (CBO). According to the 2020 census, there are 12.8 million people living in the state of Illinois with 80 percent of that population enrolled with BCBS of Illinois. Based on these statistics, that would suggest that 10.2 million residents in Illinois are enrolled for healthcare coverage through BCBS. In terms of a business perspective on a revenue standpoint, BCBS of Illinois coverage should always be a high focus for any facility solely for the revenue aspect when patients are seen.

Tip 1: Understanding your EDI clearinghouse

All hospitals throughout Illinois should have an intimate understanding of what is required from front-end registration to denial management to streamline revenue as best as possible for this large number of insured individuals with one carrier. BCBS of Illinois requires the use of an insurance web portal or clearinghouse, so it is important to understand the range of products that portal provides. This will help maximize efficiency and avoid unnecessary denials to keep aging clean and healthy for this large volume carrier.

Tip 2: Checking eligibility – the key to clean claims

On a front-end/registration point of view, utilizing running eligibility is a simple starting point to ensure your claims are being sent to the appropriate address. Whether a patient’s coverage is through an Independent Practice Association (IPA), Managed Care Organization (MCO), Labor Fund, Federal or traditional BCBS, checking eligibility is the first step to avoid any unnecessary submissions or claim status inquiry attempts.

Tip 3: Utilizing AIM to help decrease denials

After eligibility is confirmed and the patient’s benefits based on the services have been provided, utilizing the AIM portal within the insurance web portal is another excellent tool for preauthorization purposes. The AIM portal allows you to look up the services a patient is scheduled to receive and verify if that specific CPT® code requires a preauthorization. As a vendor, the most common denials we see with our hospitals are specifically from the clinical denial aspect. This denial category would pertain to no authorization, medical necessity, level of care, and length of stay. With utilizing the AIM portal, this will provide an opportunity to minimize no authorization denials with a simple check if the scheduled services require an authorization or not. If your facility is not aware of this, please reach out to your provider representative to provide you this information. On a medical necessity standpoint, you may also utilize the AIM portal to initiate a peer-to-peer review for level of care or length of stay denials in efforts to overturn these denials received.

Tip 4: Improving follow-up efficiency and accuracy

Follow-up efficiency and accuracy is also important when dealing with this high-volume carrier. With roughly 10.2 million members, traditional BCBS of Illinois receives enormous amounts of calls a day regarding claim status inquires. Using an insurance web portal’s claim status tool for all claim status inquires prior to calling can help reduce unnecessary calls. This tool provides the opportunity to capture all key and necessary information needed to grasp a rough understanding of all claim status inquires. There may be times that the information captured may not be sufficient in terms of a progressive standpoint to verify if recent submitted disputes or documents are under review. Utilizing the CIR, or Claim Inquiry Resolution tool, is another effective way to verify an updated status of documents or disputes submitted, which is provided with a reference number for tracking purposes to ensure all inquiries are answered in a timely manner. Utilizing this tool helps reduce call volumes along with decreased hold times. Not only will this tool assist the efficiency of any CBO staff member but will also help vendors as well.

Tip 5: Understanding contractual reimbursement agreements

Some believe that BCBS pays at 100% of billed charges when in fact that is not the case. Typically, what happens is that it appears payments are paid in full within an Electronic Medical Records (EMR) system but in reality, the contractual adjustment is applied on the back end through the UPP Program. The Uniform Payment Program (UPP) in a sense is the contractual reimbursement solely for BCBS and individual facilities. The UPP discount can range from 25 percent to 70 percent based on services provided or the facility in general. It is encouraged to speak to your provider representative or your internal contract management department if you do not have a clear understanding of the discount BCBS of Illinois has with your facility.

Streamlining BCBS accounts

In conclusion, BCBS of Illinois provides countless opportunities to streamline this book of business with your CBOs and your vendors to help improve efficiencies which in turn will increase your revenue. Accurately utilizing all tools that BCBS and an insurance web portal provide is another opportunity to decrease denial volumes thus reduce aging. Any specific questions you may have, it is highly encouraged to reach out to your provider representative that will allow you to make your CBO and vendors more successful.

ParaRev can help

ParaRev has the expertise in working with BCBS not only in Illinois but across the country.
Our experts have a thorough knowledge of each state’s requirements and can help you with comprehensive revenue cycle services to support accurate coding, clean claims, and timely and appropriate reimbursement. Contact us today to learn more about the many ways we can help your organization.

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