No Surprises Act: How Automating can Increase Revenue

The No Surprises Act has had an outsized impact on healthcare providers, causing some to file for bankruptcy. A deeper look at this legislation and its effects shows an urgent need for automation to keep revenue coming in.

The No Surprises Act Legislation

The No Surprises Act, enacted on January 1, 2022, aims to protect patients from unexpected medical bills, particularly those arising from out-of-network providers in emergency situations or during treatment at in-network facilities.

The legislation introduces critical provisions such as:

• Out-of-Network Billing Protections: Ensures patients are not charged more than in-network rates for emergency services and certain non-emergency care.

• Open Negotiation Period (ONP): Establishes a 30-day window for providers and insurers to negotiate payment disputes.

• Independent Dispute Resolution (IDR): Provides a formal arbitration process if negotiations fail during the ONP.

Impact on Healthcare Providers

While the No Surprises Act protects patients, it has introduced several challenges for healthcare providers:

• Administrative Burden: The ONP and IDR processes involve significant manual efforts, including sifting through emails, data parsing, and managing disputes.

• Operational Inefficiencies: Manual processes and reliance on tools like Excel and Smartsheets are causing inefficiencies, especially for providers handling large volumes of disputes.

• Revenue Uncertainty: Delays and errors in managing disputes can lead to revenue losses and difficulties in financial forecasting.

Macedon + Appian: Solution Offering and Key Values

Appian's automation software, built and delivered by Macedon Technologies, offers a comprehensive solution to streamline and optimize the ONP and IDR processes, delivering several key values:

1. Automated Email Management:

   • Removes the manual sifting of ONP, IDR, and IDRE emails, reducing administrative workload.

2. Data Classification and Parsing:

   • Automates the classification and parsing of data, ensuring accurate and efficient processing of disputes.

   • Automates the tactical human actions required, enhancing productivity.

3. IDRE Selection Automation:

   • Eliminates the manual IDRE select/reselect process, achieving 100% automation throughput.

   • Continuously updates based on each organization's unique payer IDRE strategy, ensuring optimal selection.

4. Elimination of Excel and Smartsheets:

   • Replaces unstable and unscalable manual tools with robust automation, preventing file crashes and enhancing stability.

   • Supports scalability to handle hundreds of thousands of IDR records efficiently.

5. Enhanced Revenue Accountability:

   • Provides better identification and tracking of inbound revenue via ONP, IDR, IDRE reimbursements, and others.

   • Ensures greater financial accuracy and accountability, supporting improved revenue management.

By leveraging Macedon's expertise with Appian's automation software, healthcare providers can navigate the complexities of the No Surprises Act more effectively, achieving operational excellence and financial stability.  Results include:

• Hundreds of hours per month saved via automated email ingest, parse, and tasking.

  
  

• $10m in incremental revenue by ensuring all IDRs submitted are tracked.

  
  

• $3m in incremental revenue by ensuring preferred IDREs are leveraged.