By: David Ostrowsky & Brian O'Hara, Esq.

On January 1, 2022, the No Surprises Act (NSA) officially went into effect, affording protection to patients against surprise medical bills on certain types of claims, including out-of-network emergency services, ancillary out-of-network professional services rendered at in-network facilities, and air ambulance services.  While the NSA has spared countless patients from potentially devastating balance bills, its complex and ever-evolving dispute resolution process has created headaches for plans and providers alike.  Luckily, Phia Unwrapped includes NSA support services during the Open Negotiation period and, if necessary, Independent Dispute Resolution. 

Below are two examples in which Phia procured favorable outcomes for clients of Phia Unwrapped on disputes stemming from the NSA.

• There was a provider, represented by a New York law firm, that initiated Open Negotiations on an out-of-network unwrapped claim, one that did not qualify for the NSA, and thus was not subject to the NSA dispute resolution process. While the matter was presumed closed, the law firm proceeded to initiate the IDR process, using an unrelated email address for notice purposes, and when the client received notice of IDR, the window for responding through the IDR portal had expired. Phia Unwrapped swiftly intervened by leveraging The Phia Group’s industry contacts to identify the appropriate point of contact to resolve this matter. Ultimately, Phia Unwrapped submitted a formal dismissal request based on eligibility and deficiencies in notice, akin to motion practice in a judicial setting, and eventually prevailed in having the case dismissed, while also getting IDR fees waived.

• • There was another provider, one represented by a law firm notorious for dubious negotiating practices, that was involved with an out-of-network claim in excess of $100,000.00 in billed charges. While the claim was eligible for the NSA dispute resolution process, the aforementioned law firm directed the Open Negotiation notice to the wrong email address – even though the explanation of benefits (EOB) clearly included the correct email address for NSA dispute resolution purposes – meaning the group was rendered unable to negotiate the claim prior to IDR process.

Although Phia informed the law firm multiple times that it was managing this matter on behalf of the group, the law firm proceeded in initiating IDR utilizing the same incorrect email address. Consequently, the group did not receive IDR notice until several months after the submission was due and was thus unable to submit an offer through the online portal. Phia immediately worked toward resolving the situation, namely by filing a formal Request for Extension and highlighting the bad faith tactics utilized by the provider’s law firm. When the law firm’s questionable tactics were exposed, the provider ultimately agreed to withdraw the IDR dispute. Not only did Phia prevent a default judgment in IDR, but it also saved the group from having to pay anything further to the provider.

For more information about The Phia Group’s Phia Unwrapped service, please contact Garrick Hunt at GHunt@phiagroup.com.