Federal regulators said the portal used to resolve payment disputes between healthcare providers and insurers has been inundated with requests for a third-party to intervene.
The volume of disputes filed in a five-month window exceeded the amount the departments initially anticipated receiving for a full year, according to a report authored by three federal agencies, including the HHS.
About 90,000 disputes were submitted to the federal independent dispute resolution portal between April 15 and Sept. 30. About 26% of those disputes have been considered closed, with 15%, or about 3,570 reaching a payment decision.
Regulators said the delay in processing disputes is due to the complexity of determining whether the submissions are eligible for the federal dispute resolution process that relies on third-party arbiters to mediate issues.
Last year marked the first year surprise medical bills were banned in most cases after lawmakers passed the No Surprises Act the year before.
After being caught between provider and payer pricing disputes, patients were sometimes left with the remaining balance of a medical bill when a provider was out of network and the insurer would only pay some — or none — of the bill. Patients were sometimes surprised by these bills after going to an in-network facility and unknowingly being treated by an out-of-network clinician. Patients are no longer on the hook for paying the balance in most cases.
The law creates a process for providers and insurers to resolve payment disputes by entering into baseball-style arbitration. A third-party arbiter picks one payment offer, submitted by either side, as part of the independent dispute resolution process.
The report from regulators provides insight on how the arbitration system is faring so far. It helps paint a picture of how frequently the portal is being used and the types of services payers and providers found themselves fighting over. It also shows what providers have initiated the most disputes.
The vast majority of disputes originated from emergency room visits.
About 81% of disputes (excluding air ambulance services) started in the emergency room.
The entities that initiated the most disputes were mainly physician staffing and revenue cycle management firms, including TeamHealth and Envision Healthcare, private equity backed practices that staff emergency rooms around the country. As a business strategy, the two work out of network, which can lead to surprise billing if the hospital remains in network, according to a prior study from Yale researchers.
TeamHealth and Envision refute the findings of the Yale study.
TeamHealth said it has never engaged in an out-of-network or balance billing strategy. Envision said it does not employ an out-of-network strategy.
The 10 groups that submitted the most disputes accounted for 75% of all the disputes involving out-of-network emergency services and non-emergency items.
SCP Health, formerly the Schumacher Group, a physician staffing firm that also staffs emergency rooms, filed the most disputes compared to the more than 500 entities that sent in a submittal to initiate the arbitration process.
10 entities filed 75% of all disputes excluding air ambulance services
SCP Health filed more than 28,100 disputes during the reporting period, more than twice the amount of R1 Revenue Cycle Management, which filed the second most disputes.
On the other hand, UnitedHealthcare was involved in one quarter of disputes. Aetna followed behind UnitedHealthcare and was involved in 14% of disputes excluding air ambulances.
Air ambulance services represented a small percentage of the disputes filed.
Texas, Florida, Georgia, Tennessee and North Carolina accounted for 60% of all submissions.
Editor’s note: This story has been updated to include comments from TeamHealth and Envision.
