Prior to the No Surprises Act (NSA), many patients who required air ambulatory transportation received medical bills, much to their surprise, that charged excessive fees for services not covered by their insurance plan. “Surprise” bills can be difficult to dispute, especially charges billed by out-of-network providers such as ambulance services, leaving patients already “financially fragile” further strained by unanticipated out-of-pocket costs. While the NSA protects patients from “surprise” air ambulance bills, ground ambulance bills were not included in the protection. (Tramadol)

According to a newly published Health Affairs study:

• 28% of all commercially insured ground ambulance trips between 2014 and 2017 potentially resulted in a surprise bill due to out-of-network transportation services, as did 26% of nonemergency trips.
• Eighty-five percent of emergency ground transports were delivered out of network, as were 57% of nonemergency trips. These claims were covered in full by the insurer in most cases, the researchers found, with the remainder representing 28% and 26% of trips with a potential surprise bill.
• Transportation provided by private and public sector ambulances was equally likely to result in a potential surprise bill during the study period, though those incurred by private-sector companies were 52% higher for common emergency transport codes during 2017.

As reported by Fierce Healthcare, this survey reveals substantial patient liability and wide differences in pricing and billing patterns between public-and private-sector ground ambulance organizations. Additional reporting of this survey and the ambulatory service price variation observed in surprise billing can be read in recent coverage by Benefits Pro.

Additionally, an analysis from the Peterson-KFF Health System Tracker discovered about 50% of emergency ground ambulance rides and 39% of non-emergency rides resulted in an out-of-network charge for people with private health insurance.

No More Surprises – NSA Protections

The NSA, enacted as part of the Consolidated Appropriations Act, was signed into federal law after several years of negotiation between health plan insurers, employers and providers. The legislation contains new requirements for group health plans, health insurance issuers in the group and individual markets, providers, facilities, and air ambulance providers.

With final rules taking effect January 2022, the NSA now covers participants in employer-sponsored health plans and aims to provide protection from surprise medical bills for certain emergency services as well as services received from out-of-network providers at in-network facilities. The Act also mandates publicly available pricing information on provider fees in advance of treatment, as well as patient rights and responsibilities when it comes to emergency medical service, including ambulance service.

What Does the No Surprises Act Cover?

These patient care services currently fall under the guidelines of the No Surprises Act:

• Emergency visit at an out-of-network provider
• Select, non-emergency care from out-of-network providers at in-network facilities
• Air ambulance services from out-of-network providers

Ground Ambulance and Patient Billing (GAPB) Advisory Committee

As a continued Federal oversight effort, the NSA requires the Secretary of Health and Human Services, the Secretary of Labor, and the Secretary of the Treasury to establish and convene an advisory committee for the purpose of reviewing options to improve the disclosure of charges and fees for ground ambulance services, better inform consumers of insurance options for such services, and protect consumers from balance billing.

A Strategic Solution for Health Plans

Health plans need to understand their rights under the NSA legislation and price transparency mandates designed to reveal the true cost of provider health services before receiving care and submitting a claim. The best response to the NSA is an approach that is both strategic and compliance oriented. Reference-Based Pricing (RBP) is one of the fastest growing solutions in health benefits cost management to avoid unreasonable or excessive provider charges – potentially lowering the cost of coverage and employee point of purchase cost sharing.

An effective way for employer-sponsored health plans to specifically address the requirements and challenges of the NSA is to adopt a “pure” RBP plan. Many plan sponsors are adopting this strategy as a means to avoid billing arbitration though the NSA’s Independent Dispute Resolution (IDR) process. Pure RBP plans that do not contract with providers should remain unaffected by NSA because there aren’t any out-of-network claims; nor is there any determination of a median in-network rate. This deviating from using the qualifying payment amount (QPA) required by the IDR process to negotiate a disputed bill between the plan administrator and provider.

No Surprises Act: What Every Plan Sponsor Needs to Know

This white paper addresses the risks and opportunities to reference-based pricing health plans arising out of the No Surprises Act. Click here to access.

Selecting a Medical Billing Partner

aequum is a first-of-its kind tech-driven company in the complex field of medical billing. Our tech-driven team partner with claims administrators, providing them with data-driven insights, technical solutions and legal advocacy support. As your partner, aequum helps lower costs, achieve savings and support your plan member experience and success in 2023 and beyond. Please contact us if you have any questions or need support. For more information, visit aequumhealth.com.