Dive Brief:
- The CMS announced on Friday it completed its overhaul of the No Surprises Act dispute resolution process, fully reopening the resolution portal including batched disputes and single disputes for air ambulance services.
- The agency has been incrementally restoring dispute resolution services this year, after a series of lawsuits filed by a Texas provider group prompted the CMS to pause the IDR process multiple times.
- The most recent pause in arbitrations likely contributed to procedural delays and increased the backlog of disputes weighing down the system, according to a new report released by the Government Accountability Office. The report characterized the roll out of the IDR process as “challenging.”
Dive Insight:
The No Surprises Act, which went into effect in January 2022, is meant to protect patients from unexpected medical bills after receiving care from out-of-network providers at in-network facilities.
The dispute resolution process for payments between insurers and providers was meant to be simple. Parties submit a payment offer to a third-party arbiter, who then selects one amount in what is called a final-offer or baseball-style arbitration process.
However, since the NSA rolled out last year, IDR entities, providers and insurers have reported a fraught IDR process. The dispute portal has been overloaded with claims and subject to multiple pauses after being targeted by lawsuits.
The government anticipated receiving about 22,000 disputes in 2022. However, they received nearly 490,000 from April 2022 through June 2023, increasing backlogs and delays in payment determinations, according to the GAO report.
As of June 2023, 61% of disputes submitted since April 2022 remain unresolved, according to the office. Even when parties receive judgments, receiving payments remains a struggle, parties told the GAO. In one case, an initiating party said less than 10% of its disputes have been resolved, and only 3% of disputes had been both resolved and paid.
Providers sued the government over their concerns about the IDR process — causing the the process to be paused several times and further contributing to backlogs.
The suits, led by the Texas Medical Association, have alleged administrative fees, restrictions on batching claims and the definition of qualifying payment amounts favored insurers over providers in the resolution process. The court has sided with providers, including most recently in August.
In October, the Biden administration proposed changes to streamline the IDR process and reduce backlogs. The proposed rule would require more open negotiations between parties in hopes of reducing the number of disputes submitted to IDR that aren’t actually eligible for the process.
