Implementing the No Surprises Act: What We Know from Early Grievance Knowledge


By Jack Hoadley, Nadia Stovicek, and Kevin Lucia

The No Surprises Act (NSA) gives complete protections from lots of the most prevalent types of shock medical billing, and a brand new course of for figuring out out-of-network supplier reimbursement goals to manage well being care prices by limiting insurer funds for shock payments. It stays to be seen if the brand new federal legislation—applied solely final yr—will obtain these objectives.

Two lately launched experiences present a number of the first indicators of the legislation’s influence. In November, the Facilities for Medicare & Medicaid Companies (CMS) printed a report together with a high-level abstract of NSA-related complaints from customers, suppliers, payors, and others. A brand new Authorities Accountability Workplace (GAO) research additionally gives details about each complaints and unbiased dispute decision (IDR), the NSA’s binding arbitration course of to settle disagreements over fee quantities between insurers and suppliers. Taken collectively, these experiences counsel the NSA is defending customers and different stakeholders, however extra information are wanted to find out whether or not the fee dispute course of is working to comprise prices.

Background on the NSA

Earlier than passage of the NSA, shock medical billing was most typical when customers couldn’t moderately select who supplied care, equivalent to for emergency providers or ancillary providers (like anesthesia) throughout an in-network hospital keep. In these circumstances, suppliers would sometimes invoice payors a a lot greater cost than their in-network charges; if the payor refused to pay the cost in full, suppliers billed customers massive greenback quantities as “steadiness payments.”

The NSA protects customers from steadiness billing by out-of-network suppliers and amenities in emergency, air ambulance, and in-network hospital settings, and establishes a course of to resolve fee disputes. When suppliers problem payors’ preliminary funds as inadequate, the NSA requires open negotiations between the events. If negotiations fail, the legislation permits binding arbitration, the place an IDR entity selects between the fee quantities provided by every occasion. As a part of IDR, Congress assigned a key position to a market-driven fee—the qualifying fee quantity (QPA), outlined because the median in-network fee—quite than a authorities fee, equivalent to a a number of of a Medicare fee. This course of is supposed to comprise spending and, in the end, premiums—the Congressional Price range Workplace projected the legislation will decrease insurance coverage premiums by 0.5–1.0 p.c beneath developments in most years and scale back the federal deficit by $17 billion over 10 years. Furthermore, people who would have been hit unexpectedly payments profit from considerably decrease out-of-pocket prices.

Whereas customers are already seeing financial savings, course of and authorized challenges have hampered easy implementation of the IDR procedures, stalling the legislation’s goal of defending customers in a approach that comprises prices.

Launch of grievance information gives promising however restricted insights on NSA Implementation

In comparison with the speed of care utilization, comparatively few complaints have been filed: within the first 22 months since implementation, CMS reported solely 7,888 complaints that deal particularly with NSA compliance. For comparability, two commerce teams representing insurers estimate that a million claims are submitted every month for care protected by the NSA. The low grievance quantity could possibly be an indication that the NSA is stopping the overwhelming majority of steadiness payments.

Most complaints concern supplier habits. In accordance with the CMS information, 86 p.c of NSA compliance complaints had been filed in opposition to suppliers, amenities, and air ambulance entities. About two-thirds of those provider-based complaints come up from shock billing for a non-emergency out-of-network service at an in-network facility, which we interpret to imply allegations that suppliers are sending steadiness payments prohibited by the NSA. The remainder are cut up between steadiness billing for emergency providers and failures to supply good-faith estimates of a affected person’s out-of-pocket prices, as required by the NSA. Notably, out of the resolved complaints (together with each these in opposition to suppliers and people in opposition to plans), fewer than 8 p.c resulted in a CMS dedication that an precise violation passed off. Nevertheless, the report notes that these violations led to about $3 million in “financial aid.”

Far fewer complaints had been filed in opposition to non-federal governmental plans, equivalent to state or native worker well being plans, and insurers. The commonest complaints in opposition to payors—possible from suppliers—allege non-compliance with QPA necessities. A couple of quarter of the complaints directed at plans had been a couple of late fee after an IDR dedication, a main supply of frustration amongst suppliers.

Though the low variety of instances and violations is a promising discovering, it will be helpful to have a extra detailed breakdown to see which kinds of complaints had been most certainly to contain underlying violations and different patterns of noncompliance. The CMS report additionally lacks data on the supply, timing, and backbone of NSA complaints, in addition to details about grievances referred to different companies, equivalent to states, the Workplace of Personnel Administration or the Division of Labor (DOL). The new GAO report signifies that DOL acquired 12,585 NSA-related complaints throughout an analogous timeframe, however it’s unclear if these numbers are immediately comparable.

Grievance information assist prior analysis suggesting the NSA is defending customers from shock medical payments

The newest information from CMS bolster findings from a Georgetown and City Institute report inspecting the effectiveness of federal protections in opposition to steadiness billing. The report, based mostly on 30 interviews with federal and state regulators and a broad spectrum of stakeholders, concluded the NSA has typically been profitable in defending customers from steadiness billing and taking customers “out of the center” of fee disputes between suppliers and insurers. In keeping with CMS’s grievance information, the insurance coverage regulators interviewed reported comparatively few complaints rising to the extent of an NSA violation. Of the few that did, insurance coverage regulators discovered most suppliers and payors would, when requested, alter sufferers’ payments to adjust to the legislation.

That stated, stakeholders typically cautioned in opposition to declaring full victory over shock steadiness payments merely due to a low variety of complaints. Given how few customers ever complain about billing points, one state regulator identified that the very fact they’re nonetheless receiving NSA-related shopper complaints means that the legislation is “not fully defending customers.” As well as, some stakeholders instructed the low quantity of shopper complaints might partially mirror (1) an absence of public consciousness in regards to the NSA, and (2) customers’ lack of well being protection literacy, notably concerning cost-sharing obligations. Stakeholders additionally described a lag between when a service is rendered and when the affected person receives the invoice, which means steadiness billing instances won’t present up instantly in grievance techniques. These findings complicate studying low grievance quantity as a marker of NSA success.

Questions stay concerning the NSA’s value containment influence

Whereas CMS experiences low numbers of complaints and few violations of the steadiness billing ban, it isn’t clear if the NSA can also be working to comprise prices as supposed. Most consultants acknowledge that it is just too early to grasp the complete influence of the NSA on supplier costs and supplier networks, general well being prices, and premiums. Ongoing provider-driven litigation over the IDR course of and the calculation of the QPA has led to a number of pauses by the federal companies in accepting new IDR instances and adjudicating instances already within the pipeline in addition to change within the guidelines underneath which IDR operates. Because of this, we’ve got an incomplete image of IDR decision-making. The federal authorities has confronted important challenges in responding to the quite a few authorized actions, and courtroom choices have required important technical modifications to the underlying IDR processes. A latest proposed rule lays out numerous enhancements, however these won’t be applied till late in 2024.

Preliminary information present that the IDR course of has acquired a a lot greater than anticipated variety of claims. Within the first yr of NSA implementation, IDR submissions had been 14 instances greater than preliminary estimates. Notably, the new GAO report states that six of the highest ten disputes had been initiated by personal equity-backed supplier teams. The GAO report additionally signifies that disputes have elevated each quarter since April 2022, and as of June, about 61 p.c of the 490,000 disputes submitted between April 2022–June 2023 remained unresolved. Moreover, GAO cites CMS information exhibiting that the initiating occasion (sometimes the supplier) prevailed in 77 p.c of the resolved instances for the primary six months of 2023. However data stays unavailable on key particulars, such because the greenback quantities of those resolutions. Till extra data is accessible, it’s troublesome to evaluate the NSA’s influence on containing prices.

Wanting ahead

The NSA is a landmark legislation that holds substantial promise for driving down prices and defending customers. Whereas the CMS report on grievance information helps the overall notion that the NSA is stopping unfair steadiness billing, the numerous quantity of IDR exercise and the continued litigation depart us unsure about whether or not the legislation is attaining its value containment objectives. The discharge of extra information, together with ongoing grievance information and extra granular information associated to IDR outcomes, would assist policymakers assess the influence of the NSA and whether or not additional motion to guard customers and scale back system prices might be wanted.


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