It’s been three years since the No Surprises Act (NSA) took effect, reshaping how providers, payers, and patients navigate out-of-network billing and reimbursement. While the goal of protecting patients from unexpected medical bills is widely supported, the ongoing implementation of the NSA has created significant operational, legal, and financial challenges for healthcare providers—particularly those in emergency medicine and freestanding ERs.
At QMACS, we’ve worked closely with providers to help them adapt to the shifting landscape. Here’s a look at the lessons we’ve learned—and the strategies we recommend moving forward.
This article is inspired by insights shared in HealthLeaders’ “3 Years Later: Lessons Learned From the No Surprises Act”.
1. The IDR Process Remains Complex and Burdensome
The Independent Dispute Resolution (IDR) process, designed as a way for providers and payers to resolve out-of-network payment disagreements, was initially seen as a promising path to fairness. But the reality has been anything but simple.
What we’ve seen:
- Backlogs of unresolved cases
- Shifting rules and legal challenges
- High administrative burden on providers
Takeaway:
Providers need a structured process in place for IDR submissions, complete with documentation support, payment benchmarks, and a partner that understands the nuances of the process.
QMACS provides full-service IDR support, helping clients prepare strong submissions and track resolution timelines effectively.
2. Documentation and Coding Matter More Than Ever
Under the NSA, payers are scrutinizing out-of-network claims more closely. This has led to an increase in downcoded or underpaid claims, even for medically necessary and urgent services.
What works:
- Thorough documentation of medical necessity
- Proper use of modifiers and place-of-service codes
- A consistent audit process to identify weak points before submission
Takeaway:
Accurate coding and strong clinical documentation are key to successful reimbursement, especially when preparing for potential IDR.
3. Revenue Cycle Teams Must Be Proactive, Not Reactive
As NSA policies evolve, it’s not enough to simply respond to denials and underpayments. Revenue cycle leaders need to stay ahead of the changes with proactive strategies:
- Training teams on the latest compliance requirements
- Identifying underpayment patterns across payers
- Investing in data analytics to spot red flags early
Takeaway:
Organizations that treat NSA compliance as an ongoing operational strategy—not just a billing challenge—are more likely to remain financially stable.
4. Patient Communication Still Needs Attention
While the NSA focuses on protecting patients from surprise bills, it has also introduced confusion for some patients around their responsibilities and rights.
Recommended best practices:
- Provide Good Faith Estimates clearly and early
- Train staff on how to answer NSA-related questions
- Use patient portals and tools that support transparency
Takeaway:
Improving patient communication builds trust and minimizes disputes or delays in payment.
Moving Forward: How QMACS Supports NSA Compliance
As we look ahead, the No Surprises Act will likely continue to evolve. Providers need flexible, informed partners who can adapt to ongoing regulatory changes, manage disputes efficiently, and maintain strong revenue cycles under pressure.
At QMACS, we specialize in:
- IDR preparation and submission
- Coding and documentation support
- RCM strategy for emergency medicine and freestanding ERs
- Denial management and appeal services
Whether you’re still navigating the complexities of NSA compliance or need to build a proactive strategy for 2025 and beyond, we’re here to help.
Let’s talk. Contact QMACS today to ensure your team is prepared and protected.