CMS reports over 12,000 No Surprises Act violations
CMS has directed that over $4 million in monetary relief be paid to consumers or providers.
Photo: Keith Brofsky/Getty Images
The Centers for Medicaid and Medicare Services this week released a report on complaints and enforcement efforts concerning the Public Health Service Act, which includes the No Surprises Act.
As of June 30, CMS received more than 16,073 complaints. Of these, 12,077 were No Surprises Act complaints, with 1,777 being alleged violations against insurers and 10,300 against hospitals, other providers and air ambulance services.
The CMS Complaints Data and Enforcement Report has closed 12,700 complaints.
Through the CMS investigation process, CMS has directed plans, issuers, providers, healthcare facilities or providers of air ambulance services to take remedial and corrective actions to address instances of noncompliance, which has resulted in approximately $4,183,383 in monetary relief paid to consumers or providers.
WHY THIS MATTERS
The three most common complaints against providers, including air ambulance services were:
- surprise billing for non-emergency services at an in-network facility (4,286).
- surprise billing for emergency services (2,577).
- good faith estimates (1,922).
The top three most common complaints against health plans were:
- noncompliance with Qualifying Payment Amount requirements (1,035).
- late payment after Independent Dispute Resolution determinations (675).
- noncompliance with 30-day initial payment or notice of denial of payment requirements (390).
THE LARGER TREND
During the first nine months of 2023, the No Surprises Act prevented more than 10 million surprise medical bills, according to a survey by AHIP and the Blue Cross Blue Shield Association.
The No Surprises Act was signed into law on December 27, 2020. Most of the law's provisions took effect at the beginning of 2022, applying to those enrolled in commercial health insurance coverage or group health plans renewing on or after January 1, 2022.
Under the law, when anyone covered by private health insurance is treated for emergency services or at an in-network facility by an out-of-network provider, the healthcare provider, generally a hospital, is prohibited from billing a patient above the in-network cost-sharing amount.
In December 2021, the American Hospital Association, American Medical Association and others sued the Department of Health and Human Services and the other federal agencies over implementation of the No Surprises Act. They took issue with how HHS implemented the Independent Dispute Resolution process to resolve payment rates, saying the IDR favored the insurer. The interim final rule stipulated that the arbitrator must select the offer closest to the Qualifying Payment Amount, which is set by the insurer.
This August 2, the 5th Circuit Court of Appeals affirmed a district court's decision to set aside certain regulations implementing the No Surprises Act. In particular, the decision invalidates regulatory provisions governing how arbitrators are to weigh the Qualifying Payment Amount in arbitration proceedings.
The court of appeals said: "By telling the arbitrators that they must consider the QPA before all other factors, the departments place a thumb on the scale in favor of the insurer-determined QPA in derogation of the other congressionally mandated factors."
The American Hospital Association said it has long advocated for this position, including in an amicus brief in 2022 and a lawsuit against federal agencies in 2021.
Email the writer: SMorse@himss.org
