NSA and Payment Leaks

Robert Chavez, MD, President, IEPC
Providence Little Company of Mary Medical Center Torrance

Here are my pearls for this month:

NSA – No Surprise Act
NSA IDR Criteria to be disseminated to your RCM company or the CFO of your group. When submitting IDR claims, always keep in mind the 6 criteria being considered by the IDRE. These are the following:

1. QPA in the same geographic region, increased for inflation. (From 2019).
2. Level of training, provider experience, and quality and outcomes of the provider
   (Think MIPS).
3. Market share of the provider or facility.
4. The patient acuity or complexity of the case.
5. The teaching status, case mix, and scope of services.
6. Demonstration of good faith efforts or lack thereof made by the provider or plan
   to be in network, previous network rates for the last 4 years.

Payer Leaks
All private groups should make it a point to review EOBs (Explanation of Benefits) at least once or twice a year to avoid any payment leaks. It can be surprising how often incorrect payments are made even with in-network payers. Take a moment to make sure your RCM partner calculates this as a percentage of Medicare for all payers, in-network and out-of-network. With this, it will allow you to do a much faster apples to apples comparison. If you find a leak, namely, you are being paid less than your contract calls for or an out-of-network payer is paying you less for your services, then have your RCM company reach out to the payor directly and do a deep dive to see how far back the leak goes chronologically. this can sometimes lead to a nice “catch up” check from your in-network insurance carriers. Finally, you can potentially use this information during the IDR process to demonstrate potential decreases in pay by the insurance carrier affecting your Qualified Payment Amount (QPA).