No Surprises Enforcement Act receives support from American College of Radiology

The American College of Radiology has thrown its support behind new bipartisan legislation that seeks to shore up enforcement of the No Surprises Act, which aims to protect patients from surprise medical bills.

The No Surprises Enforcement Act – introduced in the House by Representatives Dr. Greg Murphy, D-N.C.; Jimmy Panetta, D-Calif.; Dr. John Joyce, R-Pa.; Dr. Raul Ruiz, D-Calif.; Dr. Bob Onder, R-Mo.; and Dr. Kim Schrier, D-Wash. – would fine health insurance companies that fail to pay physicians within 30 days after losing the independent dispute resolution (IDR) process laid out in the No Surprises Act (NSA).

The legislation does not impact the patient protections included in the NSA, nor does it raise out-of-pocket costs for patients, lawmakers said.

WHAT’S THE IMPACT

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, 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 or facility, such as a hospital, is prohibited from billing a patient above their 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 NSA.

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.

Later that year, the U.S. Departments of Labor, Health and Human Services, and Treasury issued final rules to clarify the arbitration process.

The NSA requires insurers to promptly pay physicians. If a physician or a practice considers the payment offered by the insurer to be inadequate, they can challenge the payment by using the NSA's IDR process. If the independent arbiter rules in favor of the physician, by law, the insurer must pay the physician within 30 days.

According to the American College of Radiology (ACR), reports of insurers failing to pay these arbitration awards in a timely matter are commonplace. The group cited government data showing insurance companies lose nearly eight out of ten IDR cases to physicians or other providers.

The new legislation would impose a penalty three times the difference between the insurer's initial payment and the IDR entities' ruling per claim. The claim will also be subject to interest.

"Insurance companies must be held accountable to reimburse providers for the amount determined by the IDR process," said Dr. Alan Matsumoto, chair of the ACR Board of Chancellors. "Now, insurers are often not paying at all for these services provided to patients. This refusal trend may threaten the ability of practices to provide services in their communities and restrict patient access to care that the NSA was supposed to protect."

THE LARGER TREND

During the first nine months of 2023, the No Surprises Act protected Americans from more than 10 million surprise medical bills, according to a 2024 survey by AHIP and the Blue Cross Blue Shield Association.

The NSA prevented more than 10 million surprise medical bills from healthcare facilities, providers and air ambulance providers from reaching patients, the survey showed. Another key finding: 67% of health insurance providers indicated they increased their provider networks since the enactment of the NSA, with no plans reporting decreases in provider networks.

But the research also found skyrocketing use of the IDR process. Before the law took effect, federal agencies estimated that 17,000 claims would go through the IDR process annually. In fact, between April 15, 2022, and March 31, 2023, 334,828 disputes were initiated through the IDR portal, nearly 14 times greater than the initial estimate.

Authors claimed this increase in the use of the IDR process suggests that certain providers and hospitals may be attempting to exploit the arbitration process solely to increase profits. A single dispute, as reported by CMS, 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 the volume of claims is even higher than the number of individual disputes, increasing the burden on IDR entities and driving health care costs higher through associated fees. Healthcare costs are likely to increase unnecessarily if this trend continues.