blog ImagineInsights: Your Reimbursement Realization

The bipartisan No Surprises Act is designed to curb surprise medical billing, save patients money and reduce overall health insurance premiums. The first such federal legislation passed, it holds patients liable only for their in-network cost-sharing amount and gives providers and insurers an opportunity to negotiate reimbursement. The result is drastically altered billing and reimbursement processes for which providers must be prepared or risk marked revenue loss.



Wayne Koch, President of Clearinghouse and Electronic Services for PHIcure Next
Sam Khashman, President and CEO of ImagineSoftware

Hosted by
Lauren Lewis, Marketing and Event Specialist for ImagineSoftware


The Saga of Surprise Medical Billing

Millions of Americans receive surprise bills each year, with as many as one in five emergency room visits resulting in such a charge. Ambulances are the biggest source of unexpected medical bills (51 percent), followed by emergency department visits (19 percent) and elective inpatient procedures (9 percent).

On December 27, 2020, President Trump passed and signed into law the No Surprises Act. A bipartisan and bicameral legislation that went into effect on January 1, 2022, it applies to all individual and group health plans, including self-insured plans.

An estimate by the Congressional Budget Office (CBO) has the legislation reducing commercial insurance premiums by between 0.5-one percent and saving consumers about twice that much between reduced premiums and cost-sharing. A study published in the American Journal of Managed Care (AJMC) found that it could reduce overall health insurance premiums by one-to-five percent.

The Reimbursement Rearrangement

One of the act's key components for healthcare providers and payers is that it changes the reimbursement process for claims identified as surprise bills. In the case of reimbursement disputes, these parties have the right to access an independent dispute resolution (IDR) process.

The legislation prohibits patients from being billed for the full balance when they inadvertently receive out-of-network care. It doesn't prescribe the amount that must be paid to the provider but does outline how the member's and payer's shares of the payment are determined.

The IDR process utilizes a government-approved third-party entity to choose either the payer's or provider's offered rate as a final determination. If a payer loses the arbitration, it must pay both the provider's requested reimbursement amount and the arbitration fee. Also, by going through this process, the payer risks these arbitration results being publicly listed by the Centers for Medicare & Medicaid Services (CMS).

Utilizing ImagineInsights for Improved Reimbursement Rates

When the ImagineSoftware team first learned about the No Surprises Act and its potential impact on medical practices, we decided to create an SaaS-based product — ImagineInsights — that enables our partners to be well-prepared and informed to go to the negotiating table with payers. By utilizing this payment analytics solution as an extension of their organization, our goal is for providers to receive a favorable outcome during the arbitration process, thereby achieving a higher reimbursement rate.

One way ImagineInsights aids providers in a successful IDR result is by giving providers the ability to examine their average payments by metropolitan statistical area (MSSA) and core-based statistical area (CBSA). Once this data is procured, medical practices are able to compare the payments they're receiving to those in similar regions, drill down to the procedure and payment level and conduct a side-by-side comparison.

Another feature of ImagineInsights is that it allows providers to break down how much money they're receiving directly from a payer and, subsequently, how much the patient owes. It notes average payment with denials, enabling them to track payers that continually deny reimbursement. By utilizing this data to shift strategies as necessary, medical practices can focus on working with payers that provide them with better value.

Contact us to learn about ImagineInsights and the new features regularly being added to it.