Two Issues of Major Significance to the Medical Community

Two Issues of Major Significance to the Medical Community

by Thomas LaGreca, Esq.

The Enforcement Act. The No Surprises Act (NSA) arbitration process, known as the Federal IDR has a glaring deficiency.  The enforcement of arbitration awards is placed in the hands of CMS, with the Federal Arbitration Act (FAA) not being available to turn an arbitration award into a judicially enforceable judgment.  CMS enforcement is ineffective to say the least, and the federal courts for the most part have held that the law needs to be clarified to permit judicial enforcement.  The No Surprises Act Enforcement Act, sponsored in the House by Congressman Murphy, which will triple the award amount if carriers do not pay the award in 30 days, as required by the NSA, will be meaningless without FAA availability.  All medical associations need to be throwing their support behind the Enforcement Act and msy press for the addition of the clarification making available the FAA.

Carriers Penalizing In-Network Facilities for Using Out-of-Network (OON) Providers. One of the categories eligible for NSA arbitration is “inadvertent” OON services at in-network facilities.  Intraoperative neuromonitoring providers, anesthesiologists, radiologists, and surgeons, among others, fall into this category.  Carriers, namely Elevance (Anthem Blue Cross), will soon begin penalizing in-network hospitals and ASC’s for using OON practitioners.  This is terrible for quality of care.  What if the carrier’s network is inadequate?  What if the carrier favors, on a price basis, a particular in-network provider, but the quality of care is not up to the facility’s standards?  This is a dramatic overreach by carriers to control the care at facilities purely on the basis of the lower cost to the carrier.  This is an outrageous overreach by carriers.  All medical societies must put pressure on the hospitals to in turn push back against Elevance for this outrage.

Contact Callagy Recovery

Reach out to our team of NSA recovery specialists to receive support with your claim.

Contact
The Reliability of Arbitration in Out-of-Network Claim Recovery

When you're trying to recover payment on an out-of-network claim, the biggest question isn't whether the claim has value. Usually, the bigger question is whether the path you choose will actually produce a result. Payer appeals, informal negotiation, and arbitration...

Maximizing NSA Claim Recovery Through Arbitration

When you handle No Surprises Act claims, open negotiation is the required first step. It gives both sides a chance to resolve the payment dispute before formal review begins. In practice, that stage often produces low movement, slow responses, or token adjustments...

What To Do When a Payer Ignores Your Negotiation Request

When a payer ignores your open negotiation request, you might think the claim is totally stuck. You sent the notice, the payment issue remains unresolved, and the other side gives you nothing to work with. That silence creates risk because the federal IDR process runs...

When To Push a Denial Into the NSA Arbitration Process

An insurance denial can trigger an immediate reaction on your end. Your team sees zero payment, the claim looks urgent, and the instinct is to push it forward as quickly as possible. That response makes sense, but it doesn't always lead to the best result. Some denied...

Skip to content