Patient Billing Settings for Out-of-Network Providers

athenaCollector

 

The No Surprises Act (effective January 1, 2022) protects patients from surprise medical bills for certain healthcare services where the provider or facility is out of their payer's network.

 

If the No Surprises Act Consent setting has been enabled for your practice, you’ll see the Patient Billing Settings for Out-of-Network Providers page instead of the previous existing Non-Participating Providers page. Note: You can only manage these settings in either the Non-Participating Providers page or the Patient Billling Settings for Out-of-Network Providers page; you cannot have both pages active at the same time.)

 

This page allows your practice to track in athenaOne which providers are out-of-network for which payers, and specify your patient billing preferences for those providers.

 

For details on the No Surprises Act Consent setting and configuration options, see the User Guide — athenaOne Support for Compliance with No Surprise Billing Legislation.

 

On the Main Menu, click Settings > Billing. In the left menu, under Practice Links — Providers, click Patient Billing Settings for Out-of-Network Providers

 

 

 

Page Access

  • The Patient Billing Settings for Out-of-Network Providers page became available to all customers when Open Beta began on December 17, 2021 (to enable compliance with the No Surprises Act effective January 1, 2022), and was Generally Available with the Spring 2022 release.

  • If the No Surprises Act Consent setting has been enabled for your practice, you’ll see the Patient Billing Settings for Out-of-Network Providers page instead of the previous existing Non-Participating Providers page. Note: You can only manage these settings in either the Non-Participating Providers page or the Patient Billling Settings for Out-of-Network Providers page; you cannot have both pages active at the same time.)

  • For more information on the No Surprises Act Consent setting and configuration options, see the User Guide — athenaOne Support for Compliance with No Surprise Billing Legislation.

User Access

  • You need the Billing Admin: Non-Participation user permission to access this page.

Department Access

  • You can only define patient billing settings on this page for the departments that have been enabled within the No Surprises Act Consent setting.
  • If you have access to this page, you can edit the settings on the page for any department, even if you don’t have Department Login permission to all the departments.

 

 

 

  1. Display the Patient Billing Settings for Out-of-Network Providers page: On the Main Menu, click Settings > Billing. In the left menu, under Practice Links — Providers, click Patient Billing Settings for Out-of-Network Providers.
  2. Define the following: (See the Field Reference table below for details.)
    • Default practice settings
    • Practice Settings for out of network providers
      1. Select the insurance and set of providers who don't participate in their network
      2. For the payer/provider combinations above, define the patient billing settings for the types of services needed.

        • Emergency services

        • Non-emergency services

        Note: You can only assign a department to either Emergency or Non-Emergency, but not both.

  3. Click Save Settings.

 

  1. Display the Patient Billing Settings for Out-of-Network Providers page: On the Main Menu, click Settings > Billing. In the left menu, under Practice Links — Providers, click Patient Billing Settings for Out-of-Network Providers.

  2. You can update the Default practice settings at the top of the page.

  3. To edit specific payer/provider settings, scroll down to the Existing Non-Participating Providers list at the bottom of the page.
  4. Click the update link for the payer/provider configuration you want to edit. The information appears at the top of the page.
  5. Update the fields as desired.
  6. Click Save to update or Cancel to preserve the original information.

 

  1. Display the Patient Billing Settings for Out-of-Network Providers page: .On the Main Menu, click Settings > Billing. In the left menu, under Practice Links — Providers, click Patient Billing Settings for Out-of-Network Providers

  2. Scroll down to the Existing Non-Participating Providers list at the bottom of the page. The list is ordered first by ordering number, then alphabetically by last name.

  3. Click the delete link for the payer/provider configuration you want to delete. A warning message appears. Click OK to delete the payer/provider configuration, or click Cancel to preserve it.

    Note: Deleted payer/provider configurations appear disabled in the list of providers. To restore a deleted payer/provider configuration, click the undelete link. The audit history of the provider is preserved.

 

 

 

The Non-Participating Providers page is accessible if your practice has the non-participating providers feature enabled.

 

If the No Surprises Act Consent setting has been enabled for your practice, you’ll see the Patient Billing Settings for Out-of-Network Providers page instead of the previous existing Non-Participating Providers page. Note: You can only manage these settings in either the Non-Participating Providers page or the Patient Billling Settings for Out-of-Network Providers page; you cannot have both pages active at the same time.)

 

  • Any existing rows that were in the Non-Participating Providers table will be retained in the Patient Billing Settings for Out-of-Network Providers page, with Default Setting: Post as per the remittance and hold the claim for review. You should review these rows to set an appropriate patient billing setting.
  • If your practice has customized patient balance billing workflows/logic in place, you should review the existing rows to ensure the workflow/logic meets the new legislation requirements. If you need to delete or update any custom logic, please submit a request through the CSC.

 

 

 

The athenaOne Posting Engine references your Patient Billing Settings for Out-of-Network Providers page when posting the claim adjudication found on an EOB.

 

Entering an out-of-network provider on this page informs the athenaOne posting engine that you do not have a contract with the specified payers; therefore, you do not accept any contractual adjustments that may be inferred from the remittance advice supplied by the payer. This may result in a posting override that transfers the balance to the patient.

 

Notes:

  • You cannot add workers compensation packages to the list of out-of-network providers because claim amounts for these packages cannot be transferred to a next responsible party.
  • You cannot create an out-of-network override with any government payer, including Medicare and Medicaid programs and Medicare and Medicaid replacements.

 

 

The athenaOne Posting Engine references your Patient Billing Settings for Out-of-Network Providers when posting the claim adjudication found on an EOB, to determine:

  • When to HOLD a claim for practice review
  • When to transfer the balance to the patient without a review

When attempting to post a balance transfer, the athenaOne system reviews the following claim details:

  • Billing Provider
  • Insurance
  • Date of Service
  • Department

 

The athenaOne system will move the claim to HOLD if the following conditions are true:

  • The No Surprises Act Consent setting is turned ON for the department on the claim.
  • The billing provider is included in an existing out-of-network payer/provider configuration on the Patient Billing Settings for Out-of-Network Providers page, for insurance against which transactions are being posted, and the out-of-network arrangement was in effect on the date of service indicated on the claim.
  • A reason code is present on the remittance indicating that the provider is out-of-network for the payer.

Claims are moved to HOLD for practice review, using the kick codes for No Surprise Billing review.

  • The kick codes appear in the Claim Notes section.
  • The CONTRACTUAL code is used at the charge level.

If the claim does not meet any of the criteria, the athenaOne system transfers the balance to the patient.

 

 

If athenahealth manually posts a balance transfer to a patient, we move the claim to HOLD for practice review if the above conditions are true.

  • On the Claim Edit page, a message appears to alert the user if the provider was out-of-network for the payer on the service date.
  • On the Post Payment page, a message appears to alert the user that the provider was out-of-network for the payer on the service date and the claim will be put on Hold for review.

 

 

 

This is the list of kick codes used to support compliance with the No Surprises Act.

 

For more information:

 

Kick Code Description

SURPRISEBILLRVW

 This kick code is used by the athenaOne system to HOLD the claim for practice review based on configuration in the Patient Billing Settings for Out-of-Network Providers

SURPRISEBILLADJ

Use this kick code to adjust off the remaining balance on the claim, after the claim has been reviewed and outstanding charges are not patient responsibility, per No Surprise Billing guidelines.

 

This kick code is also used by the athenaOne system to automatically adjust off a remaining balance on a claim based on your configuration in the Patient Billing Settings for Out-of-Network Providers
SURPRISEBILLPTBAL

Use this kick code to transfer the balance to the patient, after the claim has been reviewed and approved for patient billing per No Surprise Billing guidelines.
SURPRISEBILLXFR

This kick code is used by the athenaOne system when the claim is being transferred to the secondary payer per No Surprise Billing guidelines

 

 

 

 

You must review your out-of-network providers every December and renew the ones that will remain active. To renew an out-of-network provider for another year, make the End Date December 31 of the next calendar year.

  • Out-of-network providers entered or updated before December cannot have an End Date later than December 31 of the same calendar year.
  • Out-of-network providers entered or updated during December can have an End Date as late as December 31 of the next calendar year.

 

 

Default practice settings
These settings are applied to the departments for which this page setting is turned on. They apply to claims where the remittance codes suggest that the provider is out of the payer's network and there are no specific billing settings for that payer-provider combination.
For those claims, how should the patient responsibility(PR) be handled?

Select one of the following:

  • Post as per the remittance and hold the claim for review — Select this option to have the athenaOne system place the claims in HOLD for review before billing the patient.

  • Bill patients the patient responsibility amount mentioned in the remittance advice — Select this option to automatically bill the patient
    • Select the applicable types of patient responsibility:
      • Copay
      • Coinsurance
      • Deductible
Practice settings for out-of-network providers
Name

Enter a name for the posting override. The name should reflect the relevant payers and providers (for example, Aetna: All Providers Non-Par).
Description

Enter a description of the posting override.
Start Date

By date of service on the claim.

Enter an effective date for the posting override. If the date of service on a non-par claim is within the Start and End date range, the override will apply to the claim.
End Date

Enter the date when athenaOne should stop applying this posting override. The posting override will remain in effect for all dates of service through the "end date", when the non-participation arrangement will expire.

 

If a non-par provider is scheduled to enter into a contract with a payer, the End Date you enter here must be the effective date for the new contract.
Provider Filter

Click the desired option to select the providers for the override. Additional options appear, depending on your selection.

  • All
  • Provider
  • Provider Group
  • Medical Group

Click Selected to indicate that all the providers or groups you select are non-participating with the payers you will select in the next filter.

 

Click All Except to indicate that all the providers or groups do not apply to the non-participation arrangement you are creating.

 

From the Provider, Provider Group, or Medical Group multi-select list, select the providers or groups you need for the non-par override.
Insurance Filter

Select the insurance packages or insurance reporting categories for the override. Additional options appear, depending on your selection.

  • All
  • Insurance Reporting Category
  • Insurance Package

Click Selected to indicate that all the insurance packages or insurance reporting categories you select are out-of-network for the payers you will select in the next filter.

 

Click All Except to indicate that all the insurance packages or insurance reporting categories do not apply to the out-of-network arrangement you are creating.

 

In the Insurance Package or Insurance Reporting Category text boxes, enter the insurance package IDs you need for the out-of-network override, or enter a period in the box to access the Insurance Package Lookup tool and select the packages that you need.

 

From the Insurance Reporting Category list, select the insurance categories you need for the out-of-network override.
Emergency services
Filter by place of service

Select the Place of Service for this configuration.
Select Departments

Select the applicable Departments for this configuration.

 

Note: You can only assign a department to either Emergency or Non-Emergency, but not both.
For the services rendered in these departments, how should the patient responsibility be handled?

Select one of the following:

  • Bill patients the patient responsibility amount mentioned in the remittance advice — Select this option to automatically bill the patient.

    • Select applicable types of patient responsibility:
      • Copay
      • Coinsurance
      • Deductible

  • Post as per the remittance and hold the claim for review — Select this option to have the athenaOne system place the claims in HOLD for review before billing the patient..
Non-emergency services
Filter by place of service

Select the Place of Service for this configuration.
Select Departments

Select the applicable Departments for this configuration.

 

Note: You can only assign a department to either Emergency or Non-Emergency, but not both.
For the services rendered in these departments, how should the patient responsibility be handled?
When the total of payer payment and adjudicated patient responsibility is less than or equal to the patient consented amount

Select one of the following:

  • Bill patients the patient consented amount minus payer payment as patient responsibility

  • Post consented amount minus payer payment as patient responsibility and hold the claim for review

Click the show example link to see an example of the calculation.

When the total of payer payment and adjudicated patient responsibility is greater than the patient consented amount

Select one of the following:

  • Bill patients as per the remittance

  • Post as per the remittance and hold the claim for review

Click show example link to see an example of the calculation.

 
  Note: Claims without a patient consented amount are handled using the Default practice settings.

Existing Non-Participating Providers — Column Headings
ID

The system-generated ID for the posting override.
Name

The name of the posting override.
Created

The override creation date.
Last Modified

The date that the posting override was last modified.
Filters

The filter fields used to define the posting override.

 

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