No Surprises Act
Medical Transport Playbook: Part 2
By Edward R. Marasco, MPM, CMTE, EMT-P (ret.)*
As we approach the Holiday Season, we are excited about the Pitt Panthers earning an ACC Football Championship and a Peach Bowl berth. It has been a wild ride. The Panthers, along with all the other teams seeking to play in a meaningful bowl game, required execution in accordance with their playbook over the several weeks of the season and into the conference championships. For those of us facing the No Surprises Act (NSA) implementation on New Year’s Day, our approach should be thoughtful and carefully planned as well. This is the second installment of a multi part series outlining NSA playbook suggestions.
Payment Evaluation Decisions
The decision to accept health plan payments and avoid the Independent Dispute Resolution (IDR) process, is one of the key elements of operating in the new NSA world. QMC advises its Client Partners to consider the following questions:
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- Is the initial payment adequate and fair given the services provided?
- Is there an opportunity to obtain a more fair and adequate payment in the Open Negotiation Period?
- How does the payment compare with the potential IDR outcome?
With the NSA implementation just around the corner, each organization must consider the impact of the regulations on its operation. Understanding the current financial performance of the operation and projecting the impact of the NSA era reimbursement is critical. QMC recommends that each Client Partner take a measured, analytical, non-emotional approach to making such a decision. The decision should include:
- Review the Payment Against the Historic Reimbursement
Each Client Partner should understand their current (pre-NSA era) reimbursement per transport from the major health plan groups. The analysis should contrast the rates for In Network and Out of Network health plan relationships. The Out of Network analysis must consider the health plan payment AND supplemental payments on each claim from secondary payors, including patient payments. Only after this complete analysis will the provider/supplier be in a solid position to assess the financial impact of the NSA on the operation. QMC has prepared an analysis for each Client Partner using our Q-Bi tool.
- Internal Financial Analysis
Each Client Partner should consider how various reimbursement trends will impact the financial performance of the operation. An objective review of the financial performance will be useful in establishing parameters for acceptable reimbursement.
The analysis will require a detailed review of costs and computing the cost per transport. As a high fixed cost enterprise, air medical services cost per transport can vary widely based on the volume of completed, medically necessary, air medical transports.
The analysis will require a detailed review of the reimbursement per transport. Any analysis of this nature should be done at the individual payor category (e.g., Medicare, Medicaid, Commercial, Self-Pay, etc.) level, to assess the impact of changes in reimbursement from all payor types.
- Acceptable Payment Analysis
To make an objective decision regarding individual health plan payments, each Client Partner should be prepared to evaluate payments. This evaluation may be done by an approved algorithm or on a claim-by-claim basis. In each case a determination must be made:
Acceptable Payment Range
The payment should be accepted as payment in full.
Negotiable/Review Payment Range
The payment may be acceptable; however further review is needed.
Unacceptable Payment Range
This payment is unacceptable and will require activation of the IDR process.
This triage should drive the evaluation of the initial payments and any payor discussions that would occur during the Open Negotiation Process as specified under the NSA.
What Does All This Mean?
It will be very important for each provider/supplier to make objective, informed, and strategic decisions regarding the interactions with health plans around individual claims. Establishing a baseline Reimbursement Per Transport, developing a Target Reimbursement Per Transport, and trending the Probable Reimbursement Per Transport under the NSA processes is critical to an informed approach to the billing and reimbursement.
QMC will work with each Client Partner to deploy strategies to capture a fair and equitable level of reimbursement for each claim. Pursuing a fair and equitable reimbursement will:
- Ensure patients will have adequate access to medically necessary air medical services.
- Support the financial viability of air medical services operations.
- Minimize the administrative burden of the billing and reimbursement process.
- Encourage health plans 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 financial performance, every effort should be made to do so in the coming weeks and months.
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.
