No Surprises Act prevented 9 million surprise bills
However, providers who previously were able to balance-bill patients may now be using the IDR process to collect above-market reimbursement.
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As many as 9 million surprise medical bills have been prevented since January due to the impact of the No Surprises Act, according to new data published by AHIP and the Blue Cross Blue Shield Association.
Those claims from healthcare facilities and providers were subject to the protections of the law, which limit out-of-pocket costs for consumers. The number of those claims disputed by providers or facilities has far exceeded the federal government's initial prediction, the survey found.
The No Surprises Act was signed into law 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.
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 or facility, such as a hospital, is prohibited from billing a patient above their in-network cost-sharing amount. The law establishes a process for resolving disagreements on what the health plan will pay the out-of-network provider or facility, culminating in independent dispute resolution (IDR).
WHAT'S THE IMPACT?
A key question for policymakers, lawmakers, healthcare stakeholders and consumers leading to this first year of implementation was how much providers and facilities would use the IDR process. In October 2021, when establishing the first rules for the federal IDR process, the agencies overseeing the process predicted approximately 17,000 disputes initiated each year.
The government recently announced more than 90,000 disputes had been initiated by September 30, 2022. AHIP and the Blue Cross Blue Shield Association estimate the number of disputed out-of-network claims submitted to IDR was 275,000 across those 90,000 disputes, indicating substantial use of batching, and a result of many providers sending dozens of claims at once to IDR, causing significant backlogs to the system.
A single dispute as reported by the Centers for Medicare and Medicaid Services could represent a batched dispute of many claims or a group of several claims for a single visit. The Certified IDR Entities must review each claim individually, meaning a high volume of claims across many disputes increases the burden on IDR entities and drives higher healthcare costs due to associated fees.
The large number of disputes initiated, including thousands of batched claims and many found to be ineligible, indicates many healthcare providers who were previously able to balance-bill patients may now be using the federal IDR process to collect above-market reimbursement amounts. Should this trend continue, the survey found, healthcare costs could unnecessarily increase.
During the first three quarters of 2022, there were an estimated 9 million NSA-eligible claims, or about 0.5% of all commercial claims. Of these, 275,000 were submitted to IDR for dispute resolution. Health plans have received a total of 110,000 IDR batches.
THE LARGER TREND
Three physician groups are supporting a second lawsuit brought by the Texas Medical Association against the federal departments responsible for the No Surprises Act implementation.
The American Society of Anesthesiologists, the American College of Emergency Physicians and the American College of Radiology filed a joint amicus brief with the federal court in Texas on October 19 in support of a lawsuit brought by the Texas Medical Association.
The group said they support safeguarding patients from surprise medical bills but that the No Surprises Act's implementation has created serious problems for physicians and other healthcare providers.
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.
The groups were not against the legislation, they said in the lawsuit, but took issue with how HHS implemented the IDR process to resolve payment rates between provider and payer. The interim final rule stipulated that the arbitrator must select the offer closest to the Qualifying Payment Amount, which is set by the insurer.
In August, the U.S. departments of Labor, Health and Human Services, and Treasury issued final rules to clarify the arbitration process.
The three medical groups argue that implementation continues to favor insurers and the IDR process still fails to comply with the No Surprises Act statutory text.
Twitter: @JELagasse
Email the writer: Jeff.Lagasse@himssmedia.com
