Navigating the No Surprises Act often feels like a perilous fight for insurers/payors. While it may be unfair to call the system rigged, the independent dispute resolution process appears to inherently favor the initiating party.
April 2025 | Get the latest from the best RBP advocates and auditors
Industry Perspectives
Jake Kerns
Associate Counsel
Navigating NSA Nightmares
Navigating the No Surprises Act often feels like a perilous fight for insurers/payors. While it may be unfair to call the system rigged, the independent dispute resolution process appears to inherently favor the initiating party.
Based on the most recent data published by the Centers for Medicare & Medicaid Services, the initiating party, i.e. the provider, wins 84% of the time. While the determination process may be a binary baseball-style arbitration, pitting the Bad News Bears against the dynastic New York Yankees of the 1950s presents serious challenges. Whether it’s the perceived bias or a need to defend an ineligible claim, the ultimate question is how can insurers/payors put themselves in the best position to avoid defeat? Read more.
ClaimTalk
Balance Bill Protection: Often Promised, Rarely Executed
A strong balance bill defense is essential to a successful reference-based pricing health plan. But what does that look like? And how do you know what you're being offered isn't just lip service? The answer is fiduciary responsibility.
ClaimDOC Balance Bill Manager Alex Deeter and Chief Legal Officer Amy Pellegrin join this month's edition of ClaimTalk to discuss why it's important to choose a partner that sees balance bill defense as an obligation rather than a service.
Why Are There Extreme Differences in the Cost for the Same Procedure?
Hospital charges and hospital costs for the exact same procedure can vary greatly. For the purposes of this article, we compare a common procedure reported/billed hundreds of times a day by all hospitals.
The prices are wildly different in the country depending on where you go and the charging discrepancies in some instances are shocking. Even going to different hospitals in the same metropolitan area varies. Read more.
DirectAccess+ Savings
DirectAccess+™ clients and members achieve maximum protection and savings. To establish savings information, ClaimDOC analyzes commercial contract pricing from data disclosed by hospitals and health plans. The audit team performs line-by-line claim audits to help clients and members maximize their savings. Below is one recent audit result showcasing substantial savings.
Jacksonville, Florida
Four-day hospital stay following cesarean delivery with complications
Disclaimer – The analysis of any medical billing or coding is dependent on numerous facts, regulations, payer policies and codes, as well as the controlling plan description. The information contained herein is intended to provide a real-life example of opportunities for savings through ClaimDOC services but is not intended to provide medical, legal, or financial advice.
Member Experience
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