These include emergency services, ancillary services such as anesthesia, and, in some instances, non-emergency care from out-of-network providers at in-network facilities.
The law protects patients from balance billing, and any payment dispute between the provider and insurance carrier is handled by the NSA’s Independent Dispute Resolution (IDR) process.
For providers, the NSA fundamentally changes how qualified out-of-network services are paid. Insurance carriers issue an initial payment based on the Qualifying Payment Amount (QPA), which is intended to reflect median in-network rates.
In practice, these payments are often significantly lower than expected reimbursement. Without further action, the QPA amount is typically all a provider will receive.
The NSA established an IDR arbitration system, which gives providers a way to challenge low insurance payments and pursue fair reimbursement.
After the carrier issues its initial payment, the provider is entitled to initiate a required settlement period via a dispute to the insurance carrier. If the dispute remains unresolved after the mandatory settlement period is over, the provider may file an IDR arbitration and submit evidence to a neutral arbitrator supporting a higher rate.
Those who pursue IDR often recover far more than the initial QPA payment which is calculated unilaterally by the carrier and is often well below market rates.
Many providers enter the NSA process without a clear understanding of its complexity. Common issues include:
Carriers frequently challenge filings on eligibility or minor technicalities, including data entry errors, and will even use these technicalities as a pretext to avoid paying otherwise binding NSA awards.
Further, our skilled team of attorneys maintains a high level of success pursuing unpaid NSA awards through state and federal litigation.
Partnering with a trusted law firm like Gottlieb & Greenspan enables out-of-network medical providers to truly maximize NSA reimbursement.
We support providers by:
Every client is assigned a dedicated senior paralegal and team, ensuring your case gets the attention it deserves and that you always have someone to reach out to with questions.
