Since the No Surprises Act (NSA) was implemented at the beginning of 2022, it’s caused nearly as much confusion for payers, as it has benefits for patients. One of the key sources of on-going confusion for healthcare payers center on how best to identify which claims qualify under the NSA, not only because this identification is a new process, but because of the vague language within the ruling. 

Under the No Surprises Act healthcare payers are now required to determine a qualified payment amount based on Median In-Network rates for all NSA-eligible claims. The first step is to determine which claims should be processed as NSA claims. 

In a recent Future Healthcare Today interview, Lisa LaMaster, Vice President of Business Solutions at Zelis, explained some strategies that health plans and health insurers can use to help payers transition their claims to comply with the No Surprises Act while balancing savings, provider acceptance, and reducing the time to settlement.

The new rulings allow for some interpretation for determining what qualifies as an NSA claim. By casting a wide net for NSA claims identification, payers will ensure they do not exclude any claims that need to be processed using NSA guidelines. LaMaster commented that “it’s better to consider all possibilities for claims identification, as defined by the No Surprises Act, than to miss processing an eligible NSA claim. Since the regulations are open to interpretation, the net needs to be wider.” 

LaMaster commented that many payers would like to see more clarity provided by regulators around NSA claim eligibility. Payers need to determine the best way to identify their claims in order to ultimately determine which out-of-network claims qualify for NSA processing. By ensuring that the claims are processed correctly, payers can avoid fines. In the coming months, payers hope that new rulings will provide greater clarity. “Flexibility is going to be key,” said LaMaster. “Solution providers must be flexible and committed to tracking and reacting to data, regulations, and trends.” As more guidance on the regulations is provided, payers and partners will be able to decide the best way to identify NSA claims. 

Appropriate claims identification and working with the right partner can help payers overcome the challenges created by the No Surprises Act. By doing so, payers can assure their claims are being correctly accounted for, whether they are NSA or other out-of-network claims.