No Surprises Act
Medical Transport Playbook: Part 1
By Edward R. Marasco, MPM, CMTE, EMT-P (ret.)*
As we approach the end of the year, I find myself looking forward to the college football bowl season with great anticipation. Our Pitt Panthers have emerged from decades of mediocrity to be relevant once again… perhaps even an opportunity for a New Year’s Bowl appearance. With a few important games ahead of them, the key to the next few weeks will be to follow the playbook, prepare earnestly and execute at game time. For those of us facing the No Surprises Act (NSA) implementation on New Years Day, our approach should be much the same. This is the first installment of a multi part series outlining some playbook suggestions.
Network Status Decisions
The decision to operate as an In Network versus Out of Network provider/supplier with commercial payors is relevant now more than ever. There have been many facets to such a decision over the years. As QMC has advised its Client Partners we urge them to consider the following questions:
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- Philosophical: How does our status reconcile with our mission?
- Strategic: How does our status position us in the marketplace vis-a-vis the competition?
- Financial: How will our status impact our financial performance?
With the NSA implementation just around the corner, each organization must also consider the impact of the regulations on its operation. Remaining as an Out of Network provider/supplier will certainly create more complications in the revenue cycle management (RCM) process. As we stand today, it may also have a negative impact on the financial performance of providers/suppliers. However, QMC recommends that each Client Partner take a measured, analytical, non-emotional approach to making such a decision. The decision should include:
- Review Network Status Against the Mission
Each Client Partner should be evaluating how network status reconciles with the mission of the organization. How will the status impact the organization’s ability to serve the community? How will the status impact the ability to operate now and in the future? What is/should be the organization’s relationship with the major payors in the service area? These questions should receive serious consideration.
- Strategic Considerations
Each Client Partner should consider how network status will impact the operation in the context of the greater competitive marketplace. Will the organization lose business if it is not operating in network? Will the organization be able to compete for new business moving forward? What will the public perception of the organization’s status be once the NSA processes begin to unfold? The organization should understand these nuances as it considers the approach to network status.
- Current Compensation Analysis
To assess the impact of network status financially, providers/suppliers should understand their current reimbursement per transport. Such an analysis should be down for both In Network and Out of Network situations. This figure is more meaningful if it is assessed at the individual payor level. Our Q-Bi Tool has the capability to track current (and historical) reimbursement per transport to the individual plan level, so payor level reporting is relatively simple. Each Client Partner should have this baseline in mind as the organization considers its approach to network status.
What Does All This Mean?
The trend, over the last five (5) years, for air ambulance providers/suppliers has been to seek in network relationships. QMC believes providers/suppliers that have not pursued in network relationships should give serious consideration to going in network with the top payors they encounter. Of course, any in network agreement should be fair, equitable and sustain financial viability. Pursuing a fair and equitable in network relationship will also:
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- Get the patients out of the middle of payment disputes.
- Contribute to greater transparency for both insurers and providers/suppliers.
- Encourage insurers and providers/suppliers to negotiate, in good faith, to set reasonable economic parameters for the delivery of air ambulance services.
- Allow both parties to avoid the uncertainty of the Independent Dispute Resolution (IDR) process.
Your QMC team stands ready to assist each Client Partner with its journey through this decision-making process. If your organization has not already begun to consider its status, every effort should be made to do so in the coming weeks and months. As with our beloved Pitt Panthers, the march to New Years Day is a complicated one. It requires a plan, preparation, and execution.
Please reach out to your Client Success team member to discuss the next steps and get support from QMC.
*Ed Marasco is QMC’s Vice-President of Business Development and a veteran healthcare provider and administrator with over 40 years of experience in emergency medical services, reimbursement, and consulting.
