ThenosurprisesAct (NSA)

WHO: Where it Applies

- All out-of-network emergency facility and professional services

- Post-stabilization care at out-of-network facilities until such time that a patient can be safely transferred to a different facility

- Air ambulance transports

- Out-of-network services delivered at or ordered from an in-network facility

WHY: What is the Purpose

- Create Consumer Cost-Sharing: Holds consumers harmless by limiting their costs to in-network costs, including deductibles and out-of-pocket maximums

- Address Logical Care Settings:Emergency and post-stabilization care and non-emergency care in in-network facilities, fully insured and self-funded plans. Includes air ambulance services, but not ground ambulance services

- Establish a Path for Dispute Resolution:An independent dispute resolution process will trigger if parties do not reach a voluntary agreement in a 30-day negotiation period

- Set Enforcement at a State Level with Federal Backup: States have primary enforcement role. Federal enforcement will step in when states that lack authority or fail to substantially enforce the law. Federal enforcement uses civil monetary penalties

HOW: What Steps Should be Taken

- Understand how the law applies in the states where the provider or facility renders services

- Identify, benchmark, and compare current payment trends for out-of-network claims.

- Fully understand the Dispute Resolution Process to determine when to initiate a dispute

- Audit previous claims to determine if balance billing occurred when prohibited

- Stay up to date on changes through participation in the PARA NSA Q&A bi-monthly webinars

Quest ion: We recent ly perform ed bot h a t em porary pacem aker and a perm anent pacem aker procedure during t he sam e out pat ient encount er (w it h a span of 2 days.) Medicare didn? t pay for t he t em porary pacem aker procedure. Can you offer guidance t o help us get paid for bot h procedures? An exam ple w ould be 33210, follow ed by 33208 on a subsequent day

Answ er: Actually, under Medicare?s Outpatient Prospective Payment System (OPPS), the hospital was paid for both procedures, although only CPT 33208 carries the total reimbursement amount Medicare?s OPPSpayment system calculates reimbursement for a claim according to the ?Status Indicator?of the HCPCScodes reported on the same outpatient claim, regardless of the date of service Both HCPCS(33210 and 33208) are OPPSstatus J1 ? ?Hospital Part B Services Paid Through a Comprehensive APC?:

Under OPPS, only one Status J1 code will be paid, payment for all other lines will be ?packaged?to the primary (highest paying) J1 code on the same claim When CMSsets the rate of reimbursement for a ?comprehensive APC?, the rate-setting process takes into consideration costs reported from the entire body of claims submitted by facilities nationwide for the same procedure. Therefore, it?s not quite true that the hospital isn? t paid for the temporary pacemaker procedure, it?s just that its reimbursement is ?packaged?into the rate