Written by: Krystal Woodmore, CPC, CAC
Your appeal was unfavorable, and the claim has triggered the Open Negotiation Period (ONP). Now what?
The ONP is a required phase under the No Surprises Act that allows both parties to negotiate payment before entering the IDR process. Successfully navigating this stage can lead to a resolution without the need for arbitration. Here’s a guide on how to effectively navigate the ONP for air ambulance claims:
1. Understand the ONP Timeline
The ONP is a 30-day period that begins once a claim has been denied or underpaid by the payor, or the provider challenges the payment amount. This timeframe is critical, and it’s important to act quickly to initiate negotiations and resolve disputes.
- Initiate Negotiation Promptly: The provider must initiate the negotiation process within 30 days of receiving the initial payment or notice of denial. If no agreement is reached within this time, the claim may proceed to IDR.
- Mark Important Deadlines: Keep a close eye on the 30-day period and ensure that all communications and responses are timely to avoid missing critical deadlines.
2. Gather Documentation and Justifications
To strengthen your negotiating position, prepare all relevant documentation and justifications that support the payment amount you’re requesting. This includes clinical details, medical necessity, and the cost of air ambulance services.
- Detailed Medical Records: Provide clear documentation of the patient’s condition, medical interventions during the transport, and why air transport was necessary (e.g., distance to the nearest hospital, inaccessibility by ground ambulance, life-threatening conditions).
- Breakdown of Costs: Include a transparent breakdown of your charges, such as aircraft operation costs, medical crew fees, and specialized equipment used during the transport.
- Evidence of Usual and Customary Rates: If your charges align with industry-standard rates or are comparable to other air ambulance providers, provide evidence of this to support your case.
3. Prepare a Strong Case for Medical Necessity
A significant aspect of air ambulance claim disputes often centers around medical necessity. Providers need to make a compelling case as to why air transport was justified.
- Preauthorization: If the air transport was preauthorized by the payor, highlight this in your negotiations. Preauthorization strengthens your argument that transport was deemed medically necessary.
- Patient’s Condition and Circumstances: Emphasize the patient’s critical condition, the urgency of the situation, and any geographic or time constraints that made ground transport impossible or impractical.
- Supporting Documentation: Include documentation like traffic conditions, distance to the nearest appropriate medical facility, or inaccessibility of the pickup location, all of which justify the use of air ambulance.
4. Foster Open Communication with the Payor
During the ONP, it’s critical to maintain clear, professional communication with the payor. Providers should be willing to negotiate but firm on the necessity and value of their services.
- Propose a Reasonable Settlement: Start the negotiation by proposing a reasonable settlement based on your actual costs, usual and customary rates, and the specific circumstances of the transport.
- Be Open to Dialogue: While you may have a firm stance on the value of your services, be open to dialogue. Understanding the payor’s perspective and explaining your position clearly can help resolve the dispute.
- Clarify Payor Policies: If the payor challenges your claim based on their internal policies, ask them to clarify and provide documentation of their reimbursement guidelines. This can help determine whether your charges are aligned or if there are grounds for further negotiation.
5. Leverage Market Data and Industry Standards
To support your case during the ONP, utilize available market data and industry standards to justify the payment you’re seeking.
- Compare Reimbursement Rates: Research and present reimbursement rates from other payors or geographic regions for similar air ambulance services. This can help demonstrate that your charges are reasonable.
- Highlight National Benchmarks: Use national benchmarks and data from organizations such as the Association of Air Medical Services (AAMS) to show industry-standard costs and justify the rates you’re requesting.
6. Ensure Legal and Regulatory Compliance
When navigating the ONP, it’s crucial to ensure that your actions align with the legal and regulatory framework of the No Surprises Act and other applicable laws.
- Compliance with the No Surprises Act: Ensure that you have followed the dispute resolution process outlined in the No Surprises Act, including the proper initiation of the ONP and adhering to all deadlines.
- HIPAA Compliance: As with all healthcare claims, ensure that patient privacy and data security regulations are followed throughout the process. Any documentation shared with the payor must comply with HIPAA guidelines.
7. Engage Legal or Professional Help if Necessary
If negotiations stall or the payor refuses to make reasonable concessions, it may be beneficial to engage legal or professional help.
- Involve a Third-Party Mediator: If the payor is not engaging in productive negotiations, consider suggesting a third-party mediator to facilitate discussions.
- Seek Legal Advice: In more complex disputes, consulting with legal counsel who specializes in healthcare reimbursement and air ambulance services may help strengthen your position and lead to a favorable resolution.
8. Know When to Proceed to IDR
If the ONP does not result in a resolution, be prepared to escalate the claim to the IDR process. However, entering IDR can be time-consuming and costly, so ensure that you’ve exhausted all other avenues before proceeding.
- Evaluate the Costs and Benefits: Weigh the potential benefits of entering IDR against the time and resources it will take. If the payor is close to agreeing on a reasonable amount, it may be better to settle during the ONP rather than escalating the dispute.
- Prepare for IDR: If you decide to move forward with IDR, ensure that all your documentation is in order and that you have a clear, compelling case for arbitration.
Navigating the ONP for air ambulance claims requires a strategic approach focused on timely action, thorough documentation, and clear communication. By preparing a strong case and negotiating effectively, air ambulance providers can often reach a settlement without the need for IDR, saving valuable time and resources.