The No Surprises law prevented 9 million surprise bills

Photo: Mongkhonkhamsao/Getty Images

Up to 9 million surprise medical bills have been avoided since January due to the impact of the No Surprise Act, according to new data released by AHIP and the Blue Cross Blue Shield Association (BCBSA).

These claims by health care facilities and providers were subject to the protections of the law, which limit out-of-pocket payments to consumers. The number of such claims disputed by providers or facilities far exceeded the federal government’s initial prediction, according to the survey.

The law with no surprises was signed into law on December 27, 2020. Most provisions of the law took effect in early 2022, applying to those enrolled in commercial health insurance coverage or renewed group health plans. January 1 or later.

By law, when a person covered by private health insurance is treated for emergency services or at an in-network facility by an out-of-network provider, the health care provider or facility is prohibited from , such as a hospital, to charge a patient above their in-network cost-sharing amount. The law establishes a process for resolving disagreements about what the health plan will pay the out-of-network provider or facility, culminating in Independent Dispute Resolution (IDR).

WHAT IS THE IMPACT

A key question for policy makers, legislators, healthcare stakeholders and consumers leading into this first year of implementation was how much the IDR process would be used by providers and facilities. In October 2021, when the first rules for the federal IDR process were established, the agencies overseeing the process predicted about 17,000 disputes initiated each year.

The government recently announced that over 90,000 disputes had been initiated as of September 30, 2022. AHIP and BCBSA estimate that the number of disputed off-grid claims submitted to the IDR was 275,000 for those 90,000 disputes, which which indicates substantial use of batch processing and a result. many vendors send dozens of claims to IDR at once, causing significant delays in the system.

A single dispute, as reported by the Centers for Medicare and Medicaid Services, could represent a clustered dispute of many claims or a cluster of multiple claims for a single visit. Certified IDR entities must review each claim individually, which means that a high volume of claims in many disputes increases the burden on IDR entities and results in higher healthcare costs due to associated fees.

The large number of disputes initiated, including thousands of bulk claims and many of which have been found to be ineligible, indicates that many healthcare providers who were previously able to balance patient bills can now use the federal IDR process. to collect higher than market reimbursement amounts. If this trend continues, according to the survey, health care costs could increase unnecessarily.

In the first three quarters of 2022, there were approximately 9 million NSA-eligible claims, or approximately 0.5% of all commercial claims. Of these, 275,000 were submitted to the IDR for dispute resolution. Health plans received a total of 110,000 IDR batches.

THE GREAT TREND

Three groups of physicians are support a second trial filed by the Texas Medical Association against federal departments responsible for implementing the No Surprises Act.

The American Society of Anesthesiologists, American College of Emergency Physicians, and American College of Radiology filed a joint amicus brief in Texas federal court on October 19 in support of a lawsuit brought by the Texas Medical Association.

The group said it supports protecting patients from surprise medical bills, but implementing the law without surprises has created serious problems for doctors and other healthcare providers.

In December 2021, the American Hospital Association, American Medical Association and other for follow-up the Department of Health and Human Services and other federal agencies on the implementation of the law without surprises.

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 stated that the arbitrator should select the offer closest to the eligible payment amount, which is set by the insurer.

In August, the US Departments of Labor, Health and Human Services and the Treasury issued final rules to clarify the arbitration process.

The three medical groups argue that the implementation continues to favor insurers and that the IDR process still does not comply with the statutory text of the law unsurprisingly.

Twitter: @JELagasse
Email the author: [email protected]

Comments are closed.