Surprise Billing: Issues With Dispute Resolution?

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2 Min

The Out-of-Network VS. In-Network world in healthcare is changing
Source: Wakefield
April 18, 2024

If an insurance company is not complying with the Dispute Resolution Process, read on!

If we know one thing, it’s that insurance companies will do anything to pay you as little as possible. Now, with the new surprise billing changes, particularly within the Dispute Resolution process, there’s yet another avenue insurance companies may take to prevent that payment: It’s possible they just may not comply altogether.

payors

How can the vendors do that?

Well, they can’t. Or at least, they obviously shouldn’t. And hopefully, they won’t! But if they do, you still have options.

So, what can you do?

According to Centers for Medicaid and Medicare services (CMS): If a provider, air ambulance provider, or health care facility believes a health plan isn’t complying with the dispute resolution process, then they may contact the No Surprises Help Desk at 1-800-985-3059 from 8 a.m. to 8 p.m. EST, 7 days a week, to submit a question or complaint. Or, they can submit a complaint online, below. Supporting documentation may be required.

A confirmation email will be sent to the provider when CMS receives their complaint to notify them of next steps and let them know if CMS needs any additional information. To check on the status of a complaint, or to see what documentation is needed, contact the No Surprises Help Desk.

Remember:

The creation of the dispute resolution process is brand new to everyone. To compound the confusion, state level legislation is very inconsistent and varies from state to state.

But, the difference at the Federal level is that there is language specifically stating that the provider has 30 days to dispute a payment. Additionally, that the payor must ENGAGE in a negotiation process. Only if an agreement cannot be reached, then the option of arbitration becomes available.

Patient Authorization

That being said, the legislation is setup specifically to avoid arbitration and the cost associated with it, and have providers and payors settle disputes. There is evidence that if either party does not actively engage in good faith negotiations, that party will automatically lose the case if brought to arbitration. What this all boils down to is providers have 30 days from initial payment to initiate a dispute and come to an agreement with the payor.

This avenue for resolution should be a positive outcome to providers everywhere if they are organized and staffed to handle the volume.

Need more info on Surprise Billing?

We know this new legislation has brought on more questions than answers. Luckily, we are doing our research and will continue to provide our customers with as much information as we can. Click here to read more!

Our Upfront Recovery service is designed to go toe-to-toe with the payors, and third party pricing vendors. With this service, we’ve helped providers recover millions of dollars in claims reimbursements since 2006. We aren’t slowing down anytime soon! Collect Rx is uniquely positioned to take on all volumes of settlement requests from all commercial payors.

We also offer our Post-Payment Recovery services to identify underpaid claims and settle them for additional dollars. We take on this task for Aetna, Cigna, and United Healthcare commercial plans. Over time with the NSA in place we plan to broaden the commercial plans we can address under this service line.