FEDERAL NO SURPRISES ACT ARBITRATION and STATE SURPRISE BILLING ARBITRATION

Our Surprise Billing Focus

Minevich Law Group, P.C. advises healthcare providers nationwide on resolving surprise billing disputes. We represent out-of-network providers in all 50 states for Federal No Surprises Act (aka No Surprise Billing Act) arbitration, plus New York and New Jersey clients for state surprise billing matters. Our healthcare arbitration attorneys / medical insurance attorneys accomplish that by operating at the front line of a recent and developing area of the law. At our law firm, we possess an extensive and in-depth knowledge base that sets us apart from many others. Whether we are guiding clients through a particular phase of the in-house billing disputes process or managing the entire surprise billing/no surprises act arbitration process, our team provides a wide range of strategic options that can be customized to meet even the most specific surprise billing needs.

At every step of the way, we are dedicated to supporting our clients through any surprise billing issues they may encounter. From guiding them through the complex web of state and federal regulations and compliance requirements regarding surprise billing to conducting open negotiations with payers and managing arbitration claims, we go above and beyond to ensure our clients are well-positioned to resolve any disputes that may arise. Our unwavering expertise in handling these matters empowers our clients to navigate any challenges related to surprise billing confidently.

what is a surprise bill?

Many out-of-network medical providers in New York, New Jersey, and elsewhere in the United States treat patients at an in-network hospital or ambulatory surgical center. In the alternative, patients are referred by an in-network doctor to an out-of-network provider. Subsequently, these patients would receive a “surprise bill” from these out-of-network providers when patients’ health insurance plans fail to adequately reimburse these types of services, thereby leaving patients with colossal balance bills. That was a thing of the past. Several years ago, states began to pass laws to protect patients from “Surprise” out-of-network medical bills. 

For example, an out-of-network anesthesiologist administers general anesthesia to a patient undergoing cervical spine surgery. This patient is most likely using his/her in-network neurosurgeon or orthopedic surgeon and having services rendered at an in-network facility. So then, why should this patient receive a huge balance bill from the out-of-network anesthesiologist? New York Surprise Billing law, New Jersey Surprise Billing law, and Federal No Surprises Act provide that in such situations, patients will only be responsible for their in-network cost-sharing (co-pay, deductible, and co-insurance) obligation.

The “Surprise” bills would arise when patients were taken to an out-of-network facility or were seen by an out-of-network medical practitioner in the context of emergency or non-emergent [inadvertent] care, where, for example, a patient is seen by an out-of-network ancillary medical provider, such as an anesthesiologist, at an in-network facility. Whether the circumstances are emergent or inadvertent, the patient was seen by an out-of-network medical provider through no decision of the patient.  Under these laws, the patient is protected because he or she must be billed as if the patient was seen on an in-network basis.  

In 2015, New York was one of the first states to pass the Emergency Medical Services and Surprise Bills Act (the “Surprise Bill Law”). This New York Surprise Bill Law protected patients from balance bills and created an arbitration process to address any underpayment issues to out-of-network providers. New Jersey followed suit in 2018. Then, eventually, in December 2020, the United States Congress enacted the Federal No Surprises Act, which was signed into law as part of the Consolidated Appropriations Act of 2021 (Public Law 116-260). The Federal No Surprises Act (“NSA”) took effect on January 1, 2022. 

Arbitration

So, what the New York Surprise Bill, New Jersey Surprise Bill, and Federal No Surprises Act do was shift the dispute from being between a patient and his/her out-of-network provider to the dispute being between the out-of-network provider and a patient’s insurance carrier/insurer.  To resolve disputes between an out-of-network provider and a patient’s insurance carrier/insurer, the New York Surprise Bill, New Jersey Surprise Bill, and Federal No Surprises Act allow a baseball-style arbitration process. While the New York Surprise Bill, New Jersey Surprise Bill, and Federal No Surprises Act had the intended effect of removing patients from the arbitration/ independent dispute resolution process, they had the unintended consequence of drastically reducing the reimbursements made to the medical providers who handle these types of claims. More than that, entirely banking on the fact that many medical providers would not be prepared to challenge these claims on time, the insurance carriers/insurers have taken full advantage by severely reducing the medical providers’ payment/reimbursement rates. Essentially, this places the burden on the medical providers to dispute/negotiate and arbitrate these claims on time, even though these claims were once routinely paid at or near a provider’s billed charges. Once the deadline for arbitration is missed, the out-of-network provider has no other recourse, which is why many of these out-of-network providers close shop. Medical providers must be prepared to act immediately to challenge these underpayments.  

That’s where we come in. To combat these challenges, we’ve created an efficient and successful process to submit claims/disputes to Federal No Surprises Act arbitration, New York Surprise Bill arbitration, and New Jersey Surprise Bill arbitration. These arbitrations garnered high success rates (i.e., arbitration wins/awards). We know what these arbitrations/independent dispute resolution entities seek when determining proper payment for the out-of-network services in question. Our healthcare arbitration attorneys/insurance attorneys have the expertise to tackle these out-of-network claims from beginning to end efficiently to ensure that the eligible claims are submitted on time. 

Post-Arbitration Collection

After obtaining an arbitration award, the next challenge is to collect the award payment. For NSA arbitration awards, it’s common for insurance companies to delay sending arbitration award payments to medical providers. A 2023 survey found that insurance carriers only pay 52% of NSA arbitration awards. At Minevich Law Group, P.C., we specialize in handling these types of matters and have a high success rate in collecting payments post-arbitration. We engage directly with the carrier, collaborate with the Centers for Medicare & Medicaid Services (CMS), which has the authority to enforce compliance, and if necessary, pursue litigation.

  New York Surprise Billing Law Overview

The Surprise Bill Law only applies to all fully insured New York health plans. A fully insured plan means the insurance carrier provides the funds to pay for the medical treatment described in the plan. The insurance carriers—Aetna, Cigna, United, and Blue Cross, for example—provide the funding for the plan and administer it.

For claims eligible for New York Surprise Bill arbitration (aka Independent Dispute Resolution), a reimbursement dispute is submitted to an independent dispute resolution (IDR) entity to determine whether the out-of-network medical providers charged a reasonable fee.

The good news about the New York Surprise Bill Law is that unlike the New Jersey Surprise Bill Law and the Federal No Surprises Act, a medical provider has 3 years to challenge payments on the Surprise Bill. Simply put, your 3-year-old commercial claims can potentially be timely arbitrated. So, claims that you thought were dead underwater can potentially be resurrected. 

Please contact us as soon as possible so we can review your claims and determine whether they are eligible for New York Surprise Bill arbitration. 

New Jersey Surprise Billing Law Overview

Enacted in 2018, The Out-of-network Consumer Protection, Transparency, Cost Containment, and Accountability Act (“New Jersey Surprise Bill”) created an arbitration system and a cost containment for out-of-network services. This means that for emergency, urgent, or inadvertent out-of-network services, insurance carriers/insurers are mandated to treat their members/patients as if their out-of-network treatment had been rendered in-network. The goal of the New Jersey Surprise Bill was to prevent patients from suffering financially from being treated on an out-of-network basis when the choice to be treated on an out-of-network basis was not theirs.

Unlike the New York Surprise Bill Law, the New Jersey Surprise Bill applies to fully insured, self-funded, opted-in New Jersey plans. Additionally, the New Jersey Surprise Bill has a much shorter time frame for submitting eligible commercial claims for arbitration. Please contact us as soon as possible to review your time-sensitive claims for arbitration eligibility under the New Jersey Surprise Bill.

Federal No Surprises Act Overview

The NSA establishes a federal IDR process to determine the out-of-network rate in certain circumstances when a specified state law does not apply. The NSA covers emergency and non-emergent surprise / involuntary / inadvertent (Ancillary) services such as emergency medicine, anesthesiology, pathology, radiology, neonatology, assistant surgeons, hospitalists, intensivists, diagnostic services (e.g., IONM), and many more, including elective surgeries (i.e. plastic surgeries, thoracic and cardiac surgeries). 

Historically, the medical provider, under the patient’s health plan, usually had recourse against the patient for amounts not paid by the carrier.  Now, not so since the enactment of the NSA.  In other words, for claims that fall under the auspices of the NSA, the plan’s reimbursement provisions are replaced by the NSA. So, any dispute resolution would center on whether the provider was correctly paid under the law, not on the plan’s out-of-network reimbursement provisions.  So, it is essential to note that the NSA process is statutorily created and is subject to timelines separate and distinct from those instituted by insurance carriers/insurers.  

So, what does that mean for the out-of-network medical provider? The NSA IDR process is highly time-sensitive, and many out-of-network medical providers don’t have the bandwidth and expertise to take advantage of the arbitration process. For example, as of November 2023, about 30 public companies named the Federal NSA as a potential risk to their financial performance. Biswas, Soma and Yerak, Becky. “Surprise Medical Billing Law Heaps Pressure on Healthcare Providers.” WSJ, 28 November 2023.

Statistically, in the NSA arena, a large percentage of the out-of-network providers do not submit claims to arbitration and are, therefore, stuck with a fractional Qualifying Payment Amount (QPA) payment. The insurance carriers/insurers know this and pay these out-of-network providers peanuts in relation to the actual billed charges. For example, under the NSA, insurance carriers pay providers the QPA, which is biased as the health plan solely determines it and is presumably based on its median in-network rates for the same service in a similar geographic area. For example, we’ve seen claims where, on a $50,000.00 charge, the insurance carrier paid less than $1,000.00. 

Minevich Law Group, P.C. is here to help healthcare providers maximize reimbursement from insurance carriers/insurers. We are committed to expeditiously and efficiently addressing your Federal No Surprises Act arbitration and New York Surprise Bill & New Jersey Surprise Bill arbitration needs. Please contact our office today to review your claims.