NSA negotiation fees are all over the board: Vendor “A” charges $5,850. Vendor “B” charges $900. Vendor “C” charges $50.
The No Surprises Act has spawned a new Cottage Industry reaping millions of dollars for third party intermediaries.
Vendor “A” charges 15% of allowed. The higher the negotiated rate the more they earn.
Vendor “B” charges 15% of savings. The better they negotiate the more they earn.
Vendor “C” charges a flat fee per claim.
How does that compare on a $45,000 ER billed charge negotiated down to $6,000?:
VENDOR A – 15% of allowed. Fee = $900
vs
VENDOR B – 15% of Savings: Fee = $5,850
vs
VENDOR “C” – $50
SOURCE: Blue Cross and Blue Shield of Texas
April 12, 2023
A new provider dispute and negotiation process was put in place when provisions of the No Surprises Act (NSA) started for plan years beginning on or after Jan. 1, 2022.
This new, provider-initiated negotiation process, and Independent Dispute Resolution process—if negotiations fail—is only applicable to NSA-eligible claims.
Blue Cross and Blue Shield of Texas (BCBSTX) supports our group customers by handling the 30-day provider negotiation process. If the negotiation step does not resolve the dispute, BCBSTX also handles the IDR process for our customers as well.
Starting April 25, 2023, groups will begin seeing charges for these negotiation and arbitration processes on their invoice. Charges on the April bill will include disputes beginning on or after Sept. 1, 2022.
BCBSTX will not be billing groups for negotiation or IDR services we provided prior to Sept. 1, 2022. Any future fees will be billed monthly as they occur.
Dispute Negotiation Fees
This is a $50- per-claim charge for our handling of the 30-day, provider-initiated negotiation process. This charge is for our full-service approach representing the health plan and handling the negotiation with the provider. Our team’s experience is utilized to our customer’s benefit, as our claim experts can pull relevant data specific to the disputed claim and utilize it in the administration of the negotiation process.
On the bill, multiple instances of these negotiations may be batched into the same date/charge.
IDR Dispute Fees
Sometimes the 30-day, provider-initiated negotiation process does not yield a successful payment agreement. If a provider is not satisfied, they may initiate the federal IDR process. In these instances, BCBSTX will again represent our customers in the federal IDR process to ensure their compliance with the regulatory requirements and utilize our claims experience to secure the best outcome for our group customers.
If the provider initiates the federal IDR process, an additional $75-per-claim charge will be included on the bill. These charges will be combined with the negotiation fee, so individual claims going to IDR will appear as a $125 charge (combining the $50 negotiation fee and $75 dispute fee). Note, there may be some variance for batched claims.
Remember: These processes and fees only apply to the dispute process for NSA-eligible claims.
Questions: If you have questions about this billing process, please contact your BCBSTX account representative.
