Jim Bobeck: How the No Surprises Act is the Swiss Army Knife of Healthcare Reimbursement

Listen

Watch

Read

Jim Bobeck (00:05):

Folks, how are you? Thank you very much. First of all, thank you very much for having me here today. Just very briefly, I'm aware some of you may know this a lot more than others. The biggest thing I really want you to take away here is from an educational standpoint. That's really where I really want to go with this more than anything that we have going on here today. Just really quick about us, we've been doing this for 30 years. We do not work for providers. We do not work for payers. We are in the middle. So just to be clear, government contractor in the middle, but we are resolving your disputes, healthcare reimbursements, disputes and not shocking to you from an out-of-network standpoint, emergency medicine, anesthesiology, you are right at the top on that one. So just really quickly, let's do this.

(00:47)
Three takeaways. Three, if you're going to take away anything about the No Surprises Act. Number one, it is not a new law. It is now a stabilizing institution. And what do I mean by that? Leads into point two. It is a tool. What type of tool is it? It's a Swiss Army knife because it's here to help you out with your RCM. It's here to help you with your contracting. It is here to help you with your overall strategy. Do you consolidate? Do you stay independent? Do you contract? Do you not? It affects every single portion of this. And then overall number three, it is a structural shift between provider and health plan relations. Now, whether that is a ripple or whether that is a seismic shift, that is entirely up to the organization as you go forward. But what is it? Let's just talk once again.

(01:36)
No surprises. 50 years of people getting surprise bills. Congress, as it turns out, didn't like that. Those are consumers. Those are also voters. They don't want that. So what's happened? Since this has been passed, over 50 million Americans no longer get a surprise bill. They also do not get balance billed. That's the big thing. Okay, that makes sense. But wait a minute, I'm a provider. I bill, how do I now get reimbursement for my services? You now go to that health plan, but unlike in the past, they're supposed to pay you what their in- network rate is. And if you disagree with that, you are now allowed to use the arbitration process. Why is this great? This still happens, by the way, for various groups who are still out of network and don't have access to this. You had to sue, you had litigation, you had to go through horrible contracting that you just did not like and you're saying, "I don't want these rates, but this is all I can do.

(02:32)
"This is now you have a new option on the table. So for the executives in the room, what you're going to do is you're going to come out of here and you're not going to be the expert, but you're going to go talk to your billing people and say, "Go take a look at this. Are we using this? If we are, great. Where can we do a bit better?" That's where you really want to be focusing here today. And lastly, the No Snot so much an R but it is a big thing. Good faith estimates. So for elective procedures more than anything, elective procedures, you now have to give a good faith estimate of your services to them. And if a patient disagrees with your bill after the services are done, they could possibly appeal. The difference right now is about 400 bucks. But the thing in all of this, whether you can use it or not, it comes down to a very simple concept.

(03:16)
Patient choice. Did the patient have a choice in the services when they were given? If the answer is yes, it is most likely not subject to no surprises Act. If they did not, or excuse me, if they did not, they are part of it. If they did, they are not. And if this wordy slide isn't confusing to you, I'm sure this next one, no problem at all on this. If we can move on here or I can't move on.

(03:43)
Am I good to this just die? Yeah. Oh, I got it. Hold that. We're going to go back here. Oh, see, that's very clear. Look at that. I'm sure you've all got that one down. No problem at all. Take that one home with you. This is the multiple ways through which you can get into no surprises. But just remember really clearly one thing, patient choice. I'm just going to sum it up for you right there. That's where this one comes down to. The big thing though, let's talk about those strengths and what has worked. To be clear, again, 50 million Americans, no surprise bills. That's a good thing. That's also why this bill's not going to be going anywhere. There was always a lot of noise around it. There was always going to be a lot of smoke. But when you have that many people not getting bills and those voters, this was passed by partisan by Congress.

(04:24)
Even when we go to speak to Congress or we testify in Congress and we get to tell them about the bill that they pass because they kind of forgot about certain things, that part's still super clear and they're very happy about that. People get emergency services without worry. Wonderful. They do not get an out- of-pocket costs that they were not expecting, especially in this surprise billing aspect. Little noise around the program that's gotten cleaned up. Good news. The program now adjudicates, closes more cases than it does get in. That's a big thing because in the beginning there was a bit of a backlog there. That has gotten better. We were one of the first groups to get certified by CMS to do this and we are still one of the leaders in this space. The reason for that is timeliness. If you are a provider, you are a hospital executive and you want to go through this process, the normal thing that you would see is you're going to get a payment and it's going to be the median rate that a health plan would normally pay their in-network.

(05:20)
You actually may agree with that. Odds are you probably don't. And when you don't agree with that, you're then going to say, "Can we negotiate this up a little bit?" No, that's where you have arbitration. It is a process takes a few months, but you get closure. Once a case is adjudicated, we choose one side or the other. That's it. There's no King Solomon, there's no splitting down the middle, nothing-. It's one or the other. And that's been a big thing for getting efficiency. Some of the things that got to get cleaned up though a little bit very briefly is the rules around the program. The information sharing, still not great. Why is that? You all have received an EOB before. I assume so. There are so many things that have to be in that EOB from a plan that are not there right now.

(06:08)
Very basics. When you get that bill, does this apply to no surprises or not? Does it have another rule associated with it? Small little things that go along with this. Oh, by the way, this health plan, is this a self-insured plan? Is this a fully insured plan? Who is it? There are small things that make all the difference in whether you can use this or not. Those are some of the things that CMS is looking to pass a operations rule. Just our government 101 here. Congress passed an act signed by the president, Donald Trump in December of 2020. It is now a law of the land still is. But when it comes to the law, it's not always clear that everything goes with it. So that's where CMS comes in with their rulemaking and that's where they're looking to clarify. But what they're looking to clarify is just information sharing.

(06:58)
So you have a good understanding of what claims can go through, what claims can not go through. One of the things that doesn't get touched on from a CMS perspective, this is the only government program I am aware that is actually a revenue-generating government program. So in Q2 of 2025, they collected CMS $133 million. They spent $9 million in expenditures. That is public. You can find this. It's out there. You would say that is not the purpose of your government. I would agree. So therefore some of those fees, there's a big debate about the fees that CMS charges should those be dramatically reduced because it's on there right there, low-dollar disputes. Anesthesiology is a perfect example of this. For you to submit one claim, juice not worth the squeeze. You are allowed to batch putting multiple, multiple claims together. Juice is worth the squeeze.

(07:50)
That's fantastic. But still, people are getting caught in those one-offs. What do we do with that? If they can lower the fees down on this, it's going to make the program much more attractive as we go forward. Very briefly, though, I'm not going to go over this. This is the history of the program. Little bit of a rollercoaster here. But I did say stabilizing institution in the end, 2024, 2025, 2026 has been stabilized. It's moving forward, still got kinks to work out, but it's going to be like everything you've ever seen in federal healthcare medicine. One day it feels like, yeah, it's new. I don't need to worry about this. And then all of a sudden you're going to notice everything has shifted and has become a long-term program. This is exactly how most things work, especially when they are popular with consumers out there.

(08:35)
Lastly, this just shows you kind of the growing market. 2022, 200,000, 2023, a little over 600,000. 2024, 1.4. And here we go with 2025, 2.3, but that was through November. I can tell you the year finished up at 2.4 is the estimate. 2026, 2.7. Big scheme of things, though. Big scheme of things. Where does this fit in? In-network claims is still 99% for ER and also anesthesiology. So you're thinking of that 1%. This is how much juice it is starting to generate because, frankly, especially in anesthesiology, if you are on your own, this is a critical aspect. This is also supposed to be used by you in your negotiations. That is still happening. That is a good thing. There are still some people coming more in network. They're using this from a negotiation tool as they move forward. They're using it from a strategy perspective. So when you're talking about employing people, this is exactly everything that it's building into right here.

(09:34)
I already kind of mentioned this. The program's getting a little bit better. It's going faster. This is a good thing because your time is your money. You don't want to go through this process and wait five to six months. You need instant results to move forward. And the way this works is you may pay a fee to use an IDRE, but when you win, you get your fee back. That money is then your money for the next case and et cetera, that you really want to go. The health plan, by the way, when you win, they have to pay you within 30 calendar days. That is a law. I will suggest they are not doing that all the time. If you ask them, they'll say a little bit of a different story. That's fine, but that is the law that they have to pay. So there may be some enforcement by Congress in the future on that to say, "Hey, you've got to pay." But what you're also going to see is from a health plan perspective, they want to push eligibility.

(10:24)
They want to say, "If you're going to put a case in here, we want to make sure it should be here." Fine, but I will suggest also the health plans have the information in the front. If they share that with everybody, everyone's going to know upfront whether something should be there or not. Not always happening. Not a shocker here, what I'm about to say. Health plans and provider organizations have not always gotten along. Shocking, but it's out there. Lastly, on this though, let's just talk about what 2025 looks like. You can see E&M takes up most of the time here on this one. Anesthesiology is starting to have a growing size of this, but the biggest ones are those two, radiology, and then of course, air ambulance. You also see a lot of labs. Think about anything that is related to that ER visit is usually how this works.

(11:10)
So, for instance, we even see podiatry come in. It was a consult service provided to someone while they're in the ER. That is a service to which can be billed. Very briefly, I'm not going to spend a lot of time here, but you do need to know this. This is public information that is out there. All you can see is on a state-by-state basis, the biggest users of it. Initiating party, that is a provider offer, non-initiating party. That is a payer offer. That is a sizable difference. This is still three, four years in there. This is the difference in this and this is why it's become very critical for some organizations how they want to move forward on this. Very lastly, we're happy to talk about this all day. This is purely from an educational standpoint. This is just to bring it in. It's a tool.

(11:57)
It's a tool for you to know about. That's one. Two, ultimately, it's a seismic shift. It is happening. And the biggest thing, number three, it's not a new law is now become a stabilizing force. It's part. Something everyone has to just think about as you move forward. With that being said, Bob, thank you very much. Appreciate it.

Be Our Guest

Do you have an anesthesia perspective to share? We’re always looking for healthcare leaders to discuss the industry's most pressing challenges. Apply below for a chance to be featured.