For clinicians and practice managers, the takeaway is simple: billing errors and outdated enrollment data can now directly threaten revenue, compliance, and patient relationships. This is where consistent credentialing and ongoing communication become your best defense.
What the No Surprises Act Actually Does
The No Surprises Act (NSA) aims to protect patients from unexpected out-of-network charges in specific situations and improve billing transparency.
- Protects patients from surprise balance billing in emergency care, certain ancillary and non-emergency services at in-network hospitals, and air ambulance care.
- Requires accurate provider directory data and clear patient notices so individuals are not unknowingly treated out-of-network. If the patient was not properly informed, the provider may not be able to charge out-of-network rates.
- Creates a formal dispute resolution process (Independent Dispute Resolution – IDR) between payers and providers to handle payment disagreements, using defined benchmarks like the Qualifying Payment Amount (QPA).
IDR cases can be costly and unpredictable. Prevention, through accurate data and communication, is far cheaper and more effective than arbitration.
Why This Matters for Your Practice’s Bottom Line
1. Misclassified or Unlisted Providers = Lost Revenue
If a provider’s information is outdated in payer directories or their credentials have lapsed, patients could receive care believing they’re in-network. This often results in claim denials, delayed payments, or regulatory issues. Even temporary staff or independent contractors can inadvertently trigger surprise billing issues.
2. Operational Costs and Compliance Burden
Maintaining compliance with the NSA’s requirements—such as good-faith estimates, directory verification, and patient notices—creates added administrative costs. The IDR process also brings potential expenses, as preparation and documentation for disputes can be time-consuming.
3. Reputation and Patient Retention
A single surprise billing incident can seriously harm patient trust and generate complaints or regulatory scrutiny. Rebuilding that trust can take years, especially in competitive health markets.
The Often-Missed Link: Credentialing and Continuous Engagement
Credentialing is no longer a one-time administrative task. Under the NSA, it has become a compliance checkpoint tied directly to billing accuracy and patient protection.
- Directory Accuracy Depends on Credential Data: Payers rely on credentialing records to update directories. Inaccurate credentials can make a provider invisible or incorrectly listed, creating billing risk.
- Contract Integrity Requires Ongoing Monitoring: Changes in payer contracts or delegated arrangements can lead to unintentional out-of-network billing if not updated promptly.
- Dispute Preparedness: When disputes occur, having updated credentialing records, contract documentation, and an audit trail gives providers a stronger position during IDR proceedings.
Action Plan for Providers
Immediate (Next 30 Days)
- Audit all provider directory listings across payers. Verify NPI, taxonomy, locations, contact details, and credentialing dates.
- Confirm participation status for independent contractors or locum tenens providers.
- Review patient notice and consent forms to ensure NSA compliance.
Quarterly
- Reconcile internal rosters with payer directories and document updates.
- Train front desk and billing teams to verify network status and educate patients on cost estimates.
Annual
- Perform full credentialing reviews and renewals for all providers—licenses, DEA, board status, malpractice, and affiliations.
- Maintain clear documentation of all credential updates and payer communications.
Practical Controls That Reduce NSA Risk
- Centralized credentialing calendar with alerts to prevent lapses and outdated records.
- Standard operating procedures (SOPs) for enrollment submissions and proof retention to avoid disputes.
- Periodic directory reconciliation to correct inaccuracies before patients encounter them.
- IDR readiness toolkit containing QPA references, historical claim data, and negotiation evidence for fast dispute resolution.
How Apaana HealthCare Minimizes NSA Exposure
At Apaana HealthCare, our annual maintenance model is designed for the modern compliance environment created by the NSA.
- Continuous Data Hygiene: We maintain accurate provider records, submit timely updates to payers, and routinely reconcile directories to prevent surprise billing risks.
- Enrollment & Contract Monitoring: Apaana tracks expirations, renewals, and delegated contracts, ensuring no provider slips out of network unexpectedly.
- Dispute Readiness: If an IDR case arises, we prepare complete documentation—claims history, prior contracts, and QPA data—so your team is ready to respond confidently.
- Comprehensive Audit Trail: Every update and submission is logged for easy verification, offering peace of mind during CMS or payer reviews.
Quick Checklist You Can Use Today
- Audit payer directories for accuracy
- Confirm participation for all practicing providers
- Schedule quarterly credentialing reconciliation
- Update patient notices and forms
- Prepare an IDR readiness toolkit
Final Thought
The No Surprises Act represents a shift in healthcare accountability. Providers are now equally responsible for transparency, billing accuracy, and compliance. By embracing ongoing credentialing and proactive communication, practices not only protect themselves from penalties and disputes but also strengthen trust with patients.
With Apaana HealthCare, you gain a partner that helps you stay compliant, confident, and financially secure in a rapidly changing regulatory landscape.
