Dive Brief:
- Doctors are accusing health insurers of ignoring surprise billing decisions passed down by third-party arbiters, or declining to pay them in full, according to Americans for Fair Health Care.
- AFHC, a recently formed clinician advocacy group, surveyed medical providers and found payers didn’t reimburse doctors in more than half of all awards from surprise billing decisions.
- Doctors also said payers rejected independent dispute resolution determinations as “unenforceable” and “not binding.”
Dive Insight:
The survey of more than 48,000 physicians in 45 states found payers are delaying award payments and sometimes completely denying them, which AFHC said risks destabilizing the No Surprises Act passed by Congress that went into effect early 2022.
No Surprises aims to protect consumers from pricey medical bills resulting from disputes between providers and payers, particularly when patients unknowingly receive care from an out-of-network provider at in-network facility.
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.
That process started last year but quickly ran into a number of roadblocks, including a backlog in disputes that can push decisions (and subsequent reimbursement for providers) back months as regulators received a tsunami of requests for intervention in billing disputes. In addition, provider groups have filed a string of litigation challenging the system that forced regulators to revamp how providers and insurers hash out disputes earlier this year.
According to AFHC’s survey, after the dispute resolution process, 33% of all claims paid were made in an incorrect amount; 52% of arbitration-determined payment amounts weren’t paid at all; and 49% of claims that were paid were ultimately paid late.
It’s the latest poll of physicians alleging insurers aren’t complying with arbitration decisions. Another survey of emergency room doctors conducted last year also found payers were ignoring or delaying dispute resolution claims.
The CMS did not respond to a request for comment on how many complaints they’ve received regarding the arbitration process.
Payers argue that No Surprises has also proved a significant burden on them, due to doctors appealing a large volume of billing decisions and requirements that they to update provider directories.
The law has not been entirely effective in preventing surprise bills, as one in five Americans still report receiving them. That’s in part due to exceptions to the law, including its exclusion of ground ambulances, despite them being a common source of out-of-network bills.
A committee formed by No Surprises to advise the HHS on how to prevent ground ambulance balance billing on consumers will meet later this month.
