The No Surprises Act, hailed as a law that would prevent patients receiving shockingly high bills for out-of-network services, and passed in 2021, may be having unintended consequences with the government’s projections about the number of disputes it would create looking too rosy compared with reality.
That’s according to Christine Cooper, CEO of aequum, a company that helps resolve payment disputes involving medical bills.
When the federal government enacted the No Surprises Act (NSA) to lessen payment disputes between a patient or a health insurance plan and a provider, the government projected 22,000 disputes in 2022. However, between April and September alone there were more than 90,000 disputes filed.
“The patient doesn’t even know all of this is going on and they’re the ones who are most affected because it’ll cause their premiums to go up, their deductible to go up, and ultimately, the costs for them will go up,” said Cooper. Her company works with third party administrators to resolve disputes so that patients don’t have to.
The NSA was implemented in January 2021 to protect people under group and private health insurance plans. The act bans certain practices, like surprise bills for an anesthesiologist a patient may see while already at the hospital, and who is out of network, for example.
As Cooper described, the way the process works now is the payer makes the initial payment. Then, the provider accepts the payment and if they don’t accept it and think they’re owed more, they start an open negotiation period. If they can’t resolve it, the provider may choose to settle it in an independent dispute resolution process (IDR).
In the five months since the federal portal for initiating the IDR process launched, parties initiated more than four times the number of disputes than the government anticipated for the whole year, according to data released in October by the Centers for Medicare and Medicaid Services. There aren’t enough staff to handle this surplus, Cooper said.
“What we’re seeing are IDR entities aren’t making their deadlines and this is a very time-driven process,” Cooper said.
There are only 13 IDR arbitrators and one is not accepting new disputes. “Each arbitrator is handling the process differently with some by e-mail, and some by their own portal so it is difficult to track and monitor. Arbitrators are also not following the deadlines, but rather pausing the acceptance of offers upon receipt of new disputes,” Cooper said.
There is a silver lining, according to Cooper. “We’re still early on this legislation,” she said, adding that her company’s job is to educate healthcare providers and healthcare plans about the process along the way. What’s needed now, she believes, is for CMS to provide clearer guidance. For example, before the NSA went into effect, if a provider wasn’t happy with a bill, they’d appeal to the insurance company or the payer. Now that process has gone out the window.
More entities need to be incentivized to handle these claims so there aren’t so many delays and such a backlog of claims. CMS lists the certified arbitrators on its website, and is still accepting applications.
Photo: KLH49, Getty Images
