The federal No Surprises Act (NSA) has generated millions of complaints but serves to protect consumers from unexpected out-of-pocket healthcare costs, according to a new survey.
AHIP, a U.S. health insurance trade group, and the Blue Cross Blue Shield Association (BCBSA) released a report that estimates the NSA prevents more than 1 million surprise bills per month. The results come from a survey of 21 health insurance companies, which represent 139 million commercially insured people.
Health insurers reported enrollments and claims received and paid from January to September 2023, with data on claims eligible for the NSA and those submitted to the Independent Dispute Resolution (IDR) process.
Result: An estimate of more than 10.15 million NSA-eligible claims. Most of these (more than 8.02 million) were settled when doctors and other healthcare providers began accepting payments from insurers. According to AHIP and BCBSA, an estimated 2.46 million NSA-eligible claims were in open negotiations and 668,326 were subject to Independent Dispute Resolution (IDR).
“But the data suggests that despite numerous complaints to the Independent Dispute Resolution (IDR), parts of the law appear to be aimed at protecting consumers and clarifying payments,” the report said.
How it works:
When patients with private health insurance receive treatment for emergency services or in-network facilities from out-of-network healthcare providers, the providers or facilities cannot charge the patient for In-network cost-sharing from the listed network AHIP and BCBSA amounts.
According to the U.S. Centers for Medicare & Medicaid Services, out-of-network providers were previously able to charge their patients a “balance bill,” or the difference between the provider’s bill and the amount paid by the patient’s health insurance.
The No Surprises Act should protect patients from these surprise bills. The IDR process resolves disagreements over what health insurers pay to doctors, hospitals, or other out-of-network providers or facilities, according to AHIP and BCBSA.
Claim Volume:
US The Centers for Medicare & Medicaid Services (CMS) allows batches of multiple claims or a group of multiple claims for a single visit. Certified IDR facilities must audit each of them, “which means the amount of damage is even greater than the number of individual disputes, increasing the burden on IDR facilities and Healthcare costs from associated fees,” it said Report.
The large number of disputes suggests that many healthcare providers who previously had Balanced billing may now be using IDRs, “presumably in the hope of receiving above-market reimbursement amounts,” the report said. “If this trend continues, health care costs are likely to increase unnecessarily,” the report said.
Network expansion:
Lawmakers wanted the No Surprises Act to provide incentives for doctors and other healthcare providers to join insurance networks to limit patients’ exposure to out-of-network costs and thereby protect them from unexpected bills, the report said.
This appears to be working as none of the responding health insurers reported a decrease in network size; all said they plan to maintain or increase the number of providers on their networks.
Doctors and hospitals respond
The Texas Medical Association (TMA) has been one of the harshest critics of elements of the NSA. The association won legal victories in four separate lawsuits against HHS, the Department of Labor, and the Treasury Department because its implementation “contradicts the intent of Congress and distorts the IDR process to benefit payers.”
The American Hospital Association has also raised objections to some elements of the No Surprises Act, noting that federal regulators are currently in an open public comment period for a proposed rule to improve the IDR process.
Effects of the law
When the law took effect in 2022, US federal analysts said. The Departments of Health and Human Services, Labor, and Treasury estimated that about 17,000 claims per year would be processed through the IDR. In June 2022, AHIP and BCBSA made healthcare headlines when they investigated and estimated more than 2 million surprise medical bills for the first two months of 2022.