The realm of commercial insurance healthcare reimbursement has undergone a remarkable transformation with the introduction of Surprise Billing legislation at both state levels and through the Federal No Surprises Act. For healthcare providers operating across different states, it is essential to deeply understand each law and how they interact with one another. Determining which law takes precedence in a given situation depends on evaluating the treatment’s context, the nature of the billing dispute, and the jurisdiction in which the dispute is adjudicated.

The context in which treatment is provided plays an important role. Emergency services and inadvertent out-of-network care, such as when an out-of-network ancillary service provider rendered services at an in-network facility or ambulatory surgery center, are typically covered under state surprise billing laws and the Federal No Surprises Act. However, if both the surgeon and facility are chosen as out-of-network by choice, then neither the state surprise billing arbitration process nor the Federal No Surprises Act apply, although certain disclosure requirements still need to be met by the out-of-network provider. However, nothing is set in stone. With the Federal No Surprises Act being so recent, there might be claims covered by it that you hadn’t anticipated.

It’s important to distinguish between underpayments/administrative denials and medical denials regarding payment issues. Providers of intraoperative neurophysiological monitoring (IONM) often encounter disputes labeled as “experimental/investigational” (often by Aetna or Cigna) that do not fall under the auspices of the Surprise Billing arbitration process and the Federal No Surprises Act arbitration process. Understanding this difference is crucial for effectively navigating the appropriate appeals process and ensuring timely actions are taken.

Suppose a dispute falls under the ambit of a state Surprise Billing law or the Federal No Surprises Act involving an underpayment or administrative denial. In that case, the next step is to decide whether to pursue the matter at a state or federal level. This largely depends on whether the state has its own Surprise Billing law, with state forums addressing claims related to state-regulated plans and federal forums dealing with federally regulated and potentially out-of-state plans. For states without their own Surprise Billing laws, the Federal No Surprises Act serves as the governing law for all plans. Identifying the type of insurance plan and the laws applicable in the treatment’s state are essential steps.

An important nuance regarding the Federal No Surprises Act is that these local standards supersede federal law if a state has an All Payor Model Agreement or specific legislation for compensating emergency or inadvertent out-of-network services like IONM. This scenario favors providers in states with more advantageous local reimbursement standards than those otherwise subject to less beneficial benchmarks, such as Medicare rates.

As the legal landscape surrounding these issues evolves, staying informed and seeking legal counsel is crucial to effectively navigate the complexities of commercial insurance reimbursement recovery. While the environment is expected to stabilize over time, staying vigilant and obtaining professional advice remains critical during this transition period.