Practice Management

Does anyone know how I would find official ruling on this.

If a patient has an EPO policy.  The policy says:  No out of network benefits.

The patients claim is denied saying:  all patients responsibility because it is an EPO

However, the patient went to a hospital and radiologists are out of network.

In other circumstances this would qualify for:  the No Surprises Act.

Could a company get out of the No Surprises Act by getting a policy that is an EPO?  

Thank you for your thoughts.

Gayle Schreier

Business Manager

Roper Radiologists

843-475-3931

Gayle.schreier@rsfh.com

Hi Gayle

I don't think there is any exception for EPO's.  The NSA generally covers group and individual insurance plans.  The key question is probably whether the service is governed by the NSA balance billing limitations, i.e. was it an emergency service or rendered by at an in-network facility?  If one of those criteria is met, then the patient should get in-network benefits, and the initial payment should be issued to the provider.

You should be able to appeal to the payor, and if that doesn't work go to the state insurance regulator and/or CMS.  We've had to appeal several cases where the initial claim wasn't processed in accordance with NSA rules initially. 

Dave

Does anyone know how I would find official ruling on this.

If a patient has an EPO policy.  The policy says:  No out of network benefits.

The patients claim is denied saying:  all patients responsibility because it is an EPO

However, the patient went to a hospital and radiologists are out of network.

In other circumstances this would qualify for:  the No Surprises Act.

Could a company get out of the No Surprises Act by getting a policy that is an EPO?  

Thank you for your thoughts.

Gayle Schreier

Business Manager

Roper Radiologists

843-475-3931

Gayle.schreier@rsfh.com

David is correct; here is the Departments Aug. 2022 FAQ and citations of authority:

The Federal Departments tasked with implementing the No Surprises Act have explicitly stated that these types of plans are subject to the requirements of the No Surprises Act. In a set of frequently asked questions (FAQs) issued on August 19, 2022, the Departments address the issue:
Q6: Do the surprise billing provisions of the No Surprises Act apply in the case of a group health plan or group or individual health insurance coverage that generally does not provide out-of-network coverage?
Yes. The No Surprises Act's protections regarding emergency services, non-emergency services furnished by a nonparticipating provider with respect to a visit to a participating facility, and air ambulance services apply if those services are otherwise covered under the plan or coverage, even if the plan or coverage otherwise does not provide coverage for out-of-network items or services.
Note that, under section 9816(a) of the Code, section 716(a) of ERISA, and section 2799A-1(a) of the PHS Act, if a plan or issuer provides or covers any benefits with respect to services in an emergency department of a hospital or with respect to emergency services in an independent freestanding emergency department, the plan or issuer must cover emergency services, including on an out-of-network basis, in accordance with the No Surprises Act and its implementing regulations.14 Similarly, under section 9816(b) of the Code, section 716(b) of ERISA, section 2799A-1(b) of the PHS Act, if a plan or issuer provides or covers benefits with respect to nonemergency items and services, the plan or issuer must cover the items and services furnished to a participant, beneficiary, or enrollee of the plan or coverage by a nonparticipating provider with respect to a visit at a participating health care facility in accordance with requirements set forth in 26 CFR 54.9816-5T(c), 29 CFR 2590.716-5(c), and 45 CFR 149.120(c) related to cost sharing, payment amounts, and procedural requirements related to billing disputes. Finally, under section 9817(a) of the Code, section 717(a) of ERISA, and section 2799A-2(a) of the PHS Act, if a plan or issuer provides or covers any benefits for air ambulance services, the plan or issuer must cover such services from a nonparticipating provider of air ambulance services in accordance with requirements set forth in 26 CFR 54.9817-1T(b), 29 CFR
2590.717-1(b), and 45 CFR 149.130(b) related to cost sharing, payment amounts, and procedural requirements related to billing disputes. These requirements may result in a plan or coverage providing benefits for out-of-network items and services subject to the surprise billing provisions, even if the plan or coverage otherwise would not provide coverage for these items or services on an out-of-network basis. (Emphasis added; footnote omitted).

Hi Gayle

I don't think there is any exception for EPO's.  The NSA generally covers group and individual insurance plans.  The key question is probably whether the service is governed by the NSA balance billing limitations, i.e. was it an emergency service or rendered by at an in-network facility?  If one of those criteria is met, then the patient should get in-network benefits, and the initial payment should be issued to the provider.

You should be able to appeal to the payor, and if that doesn't work go to the state insurance regulator and/or CMS.  We've had to appeal several cases where the initial claim wasn't processed in accordance with NSA rules initially. 

Dave

Does anyone know how I would find official ruling on this.

If a patient has an EPO policy.  The policy says:  No out of network benefits.

The patients claim is denied saying:  all patients responsibility because it is an EPO

However, the patient went to a hospital and radiologists are out of network.

In other circumstances this would qualify for:  the No Surprises Act.

Could a company get out of the No Surprises Act by getting a policy that is an EPO?  

Thank you for your thoughts.

Gayle Schreier

Business Manager

Roper Radiologists

843-475-3931

Gayle.schreier@rsfh.com

Thank you very much Ed and David for great information.  I'm definitely seeing claims where the response is:  PR242.  Patient responsibility.  Entire charge is in patient responsibility.  Patient Not Covered.  (CAD235)  Benefits for this service are denied.  Under the member's plan, Benefits are only available when a network provider is used.  I guess the Insurer forgets to ad:  Unless the Federal law containing the no Surprise Act would apply.  I love this industry where (in my opinion)  I question whether the actual law matters when it comes to claims processing.  Thank you for the great legal citations.  Gayle  843-475-3931

David is correct; here is the Departments Aug. 2022 FAQ and citations of authority:

The Federal Departments tasked with implementing the No Surprises Act have explicitly stated that these types of plans are subject to the requirements of the No Surprises Act. In a set of frequently asked questions (FAQs) issued on August 19, 2022, the Departments address the issue:
Q6: Do the surprise billing provisions of the No Surprises Act apply in the case of a group health plan or group or individual health insurance coverage that generally does not provide out-of-network coverage?
Yes. The No Surprises Act's protections regarding emergency services, non-emergency services furnished by a nonparticipating provider with respect to a visit to a participating facility, and air ambulance services apply if those services are otherwise covered under the plan or coverage, even if the plan or coverage otherwise does not provide coverage for out-of-network items or services.
Note that, under section 9816(a) of the Code, section 716(a) of ERISA, and section 2799A-1(a) of the PHS Act, if a plan or issuer provides or covers any benefits with respect to services in an emergency department of a hospital or with respect to emergency services in an independent freestanding emergency department, the plan or issuer must cover emergency services, including on an out-of-network basis, in accordance with the No Surprises Act and its implementing regulations.14 Similarly, under section 9816(b) of the Code, section 716(b) of ERISA, section 2799A-1(b) of the PHS Act, if a plan or issuer provides or covers benefits with respect to nonemergency items and services, the plan or issuer must cover the items and services furnished to a participant, beneficiary, or enrollee of the plan or coverage by a nonparticipating provider with respect to a visit at a participating health care facility in accordance with requirements set forth in 26 CFR 54.9816-5T(c), 29 CFR 2590.716-5(c), and 45 CFR 149.120(c) related to cost sharing, payment amounts, and procedural requirements related to billing disputes. Finally, under section 9817(a) of the Code, section 717(a) of ERISA, and section 2799A-2(a) of the PHS Act, if a plan or issuer provides or covers any benefits for air ambulance services, the plan or issuer must cover such services from a nonparticipating provider of air ambulance services in accordance with requirements set forth in 26 CFR 54.9817-1T(b), 29 CFR
2590.717-1(b), and 45 CFR 149.130(b) related to cost sharing, payment amounts, and procedural requirements related to billing disputes. These requirements may result in a plan or coverage providing benefits for out-of-network items and services subject to the surprise billing provisions, even if the plan or coverage otherwise would not provide coverage for these items or services on an out-of-network basis. (Emphasis added; footnote omitted).

Hi Gayle

I don't think there is any exception for EPO's.  The NSA generally covers group and individual insurance plans.  The key question is probably whether the service is governed by the NSA balance billing limitations, i.e. was it an emergency service or rendered by at an in-network facility?  If one of those criteria is met, then the patient should get in-network benefits, and the initial payment should be issued to the provider.

You should be able to appeal to the payor, and if that doesn't work go to the state insurance regulator and/or CMS.  We've had to appeal several cases where the initial claim wasn't processed in accordance with NSA rules initially. 

Dave

Does anyone know how I would find official ruling on this.

If a patient has an EPO policy.  The policy says:  No out of network benefits.

The patients claim is denied saying:  all patients responsibility because it is an EPO

However, the patient went to a hospital and radiologists are out of network.

In other circumstances this would qualify for:  the No Surprises Act.

Could a company get out of the No Surprises Act by getting a policy that is an EPO?  

Thank you for your thoughts.

Gayle Schreier

Business Manager

Roper Radiologists

843-475-3931

Gayle.schreier@rsfh.com

Gayle, also be sure to file an official complaint against any health plan who claims that they are exempt.  The Dept. of Labor is actually reaching out to those who file complaints against ERISA plans to investigate non-compliance.  CMS has taken the position in some cases that without an official complaint then there are no grounds to claim non-compliance.

Thank you very much Ed and David for great information.  I'm definitely seeing claims where the response is:  PR242.  Patient responsibility.  Entire charge is in patient responsibility.  Patient Not Covered.  (CAD235)  Benefits for this service are denied.  Under the member's plan, Benefits are only available when a network provider is used.  I guess the Insurer forgets to ad:  Unless the Federal law containing the no Surprise Act would apply.  I love this industry where (in my opinion)  I question whether the actual law matters when it comes to claims processing.  Thank you for the great legal citations.  Gayle  843-475-3931

David is correct; here is the Departments Aug. 2022 FAQ and citations of authority:

The Federal Departments tasked with implementing the No Surprises Act have explicitly stated that these types of plans are subject to the requirements of the No Surprises Act. In a set of frequently asked questions (FAQs) issued on August 19, 2022, the Departments address the issue:
Q6: Do the surprise billing provisions of the No Surprises Act apply in the case of a group health plan or group or individual health insurance coverage that generally does not provide out-of-network coverage?
Yes. The No Surprises Act's protections regarding emergency services, non-emergency services furnished by a nonparticipating provider with respect to a visit to a participating facility, and air ambulance services apply if those services are otherwise covered under the plan or coverage, even if the plan or coverage otherwise does not provide coverage for out-of-network items or services.
Note that, under section 9816(a) of the Code, section 716(a) of ERISA, and section 2799A-1(a) of the PHS Act, if a plan or issuer provides or covers any benefits with respect to services in an emergency department of a hospital or with respect to emergency services in an independent freestanding emergency department, the plan or issuer must cover emergency services, including on an out-of-network basis, in accordance with the No Surprises Act and its implementing regulations.14 Similarly, under section 9816(b) of the Code, section 716(b) of ERISA, section 2799A-1(b) of the PHS Act, if a plan or issuer provides or covers benefits with respect to nonemergency items and services, the plan or issuer must cover the items and services furnished to a participant, beneficiary, or enrollee of the plan or coverage by a nonparticipating provider with respect to a visit at a participating health care facility in accordance with requirements set forth in 26 CFR 54.9816-5T(c), 29 CFR 2590.716-5(c), and 45 CFR 149.120(c) related to cost sharing, payment amounts, and procedural requirements related to billing disputes. Finally, under section 9817(a) of the Code, section 717(a) of ERISA, and section 2799A-2(a) of the PHS Act, if a plan or issuer provides or covers any benefits for air ambulance services, the plan or issuer must cover such services from a nonparticipating provider of air ambulance services in accordance with requirements set forth in 26 CFR 54.9817-1T(b), 29 CFR
2590.717-1(b), and 45 CFR 149.130(b) related to cost sharing, payment amounts, and procedural requirements related to billing disputes. These requirements may result in a plan or coverage providing benefits for out-of-network items and services subject to the surprise billing provisions, even if the plan or coverage otherwise would not provide coverage for these items or services on an out-of-network basis. (Emphasis added; footnote omitted).

Hi Gayle

I don't think there is any exception for EPO's.  The NSA generally covers group and individual insurance plans.  The key question is probably whether the service is governed by the NSA balance billing limitations, i.e. was it an emergency service or rendered by at an in-network facility?  If one of those criteria is met, then the patient should get in-network benefits, and the initial payment should be issued to the provider.

You should be able to appeal to the payor, and if that doesn't work go to the state insurance regulator and/or CMS.  We've had to appeal several cases where the initial claim wasn't processed in accordance with NSA rules initially. 

Dave

Does anyone know how I would find official ruling on this.

If a patient has an EPO policy.  The policy says:  No out of network benefits.

The patients claim is denied saying:  all patients responsibility because it is an EPO

However, the patient went to a hospital and radiologists are out of network.

In other circumstances this would qualify for:  the No Surprises Act.

Could a company get out of the No Surprises Act by getting a policy that is an EPO?  

Thank you for your thoughts.

Gayle Schreier

Business Manager

Roper Radiologists

843-475-3931

Gayle.schreier@rsfh.com