Health professionals and facilities are prevailing in most out-of-network payment disputes resolved under the federal No Surprises Act, but the implementation of the law remains flawed, as indicated by a significant backlog of unresolved disputes and other issues.
This is according to new data from the Centers for Medicare & Medicaid Services (CMS) on disputes initiated during the first half of 2023, which underscore the Texas Medical Association’s continued legal advocacy regarding the No Surprises Act.
The law, which took effect in 2022, established a federal independent dispute resolution (IDR) process through which clinicians can dispute health plans’ initial payment for certain out-of-network care. A certified IDR entity arbitrates these disputes.
TMA has sued federal regulators four times over their implementation of the law, saying it conflicts with congressional intent and skews the IDR process in payers’ favor.
Amid these lawsuits, the CMS data indicate the health professionals and facilities that can access the IDR process are seeing some success, winning 77% of the 78,111 disputes where a payment determination was made involving out-of-network emergency and non-emergency services during this period.
But more than half of disputes – 55% – remain unresolved, mainly because of eligibility challenges, according to CMS. Roughly 39% of disputes faced such challenges, overwhelmingly from health plans.
Among disputes resolved via a payment determination, in approximately 82% of cases the payment determination was higher than the opaque, insurer-determined qualified payment amount (QPA) – a clear sign of TMA’s advocacy impact.
TMA’s lawsuits have challenged certain parts of the rules implementing the No Surprises Act, including those that:
- Give outsized weight or consideration to the QPA during arbitrations, which unfairly benefits payers; and
- Artificially deflate the QPA, skewing negotiations in favor of payers so strongly that payers have forced physicians out of network, exacerbating practice viability and access-to-care challenges.
The CMS data release is just one of several recent developments related to the No Surprises Act, whose implementation remains fluid and is being closely monitored by TMA. For more news and information regarding TMA’s efforts, check out the association’s Surprise Medical Bills webpage.
Emma Freer
Associate Editor
(512) 370-1383