News Update: NSA Prevents Certain Balance Bills

There is a growing expectation that consumers will have avoided 12 million surprise billing claims in this first year of the law.

We’ve just passed the No Surprises Act’s first 150 days, so let’s give the law a check-up and see how it’s doing.

In its first two months, January and February, the No Surprises Act prevented more than two million potential surprise medical bills, according to research by the American Health Insurance Plans (AHIP) and the Blue Cross Blue Shield Association.

Assuming these kind of numbers continue, we can expect that consumers will have avoided 12 million surprise billing claims in this first year of the law.

Now, to put that into context, those numbers make up less than 1 percent of all the commercial claims; in fact, they represent only about 0.2 percent. Still, it appears that the numbers are significantly more than what was predicted by the U.S. Department of Health and Human Services (HHS).

In its No Surprises Act regulation, HHS estimated that only 17,000 claims would be submitted annually to the government’s third-party arbitration process or independent dispute resolution process. But the AHIP/Blue Cross Blue Shield report indicates that about 120 times that many would actually be eligible for the dispute process.

In fact, claim dispute processes just kicked off in April, when the government portal that managed the disputes finally opened. Within the first two weeks of the portal’s opening, 3,300 disputes were initiated.

Now, as readers may remember, a number of lawsuits have been filed with regard to the methodology that arbitrators should use in the act’s dispute process. HHS published a regulation last year noting that the default reimbursement for No Surprises Act claims should be a plan’s median in-network rate.

The lawsuits brought by the American Medical Association and other provider groups argued that the median in-network rate should NOT be the default payment amount, but rather, the arbitrator should consider a number of other factors in addition to the median in-network rate, such as acuity of the patient and training and quality of the provider.

In February, a Texas court agreed with provider groups, and HHS changed its guidance to align with the decision – and all of the related lawsuits were then paused.

In April, however, HHS appealed the Texas decision, and all the lawsuits started back up again.

Then, in May, HHS paused its own appeal until it could publish a final rule on the dispute process sometime this summer.

That’s all to say that there are issues about the dispute resolution process that have yet to be, um, resolved. For one, decisions on the Texas case and related cases across the country may yet alter the methodology that arbitrators will use.

Second, as we said, HHS will be coming out with a final rule on the dispute resolution process, and it’s anyone’s guess whether that rule will agree with the Texas court or try to work around it.

Third, the government portal where payors and providers are supposed to manage the dispute process is clunky, administratively burdensome, and not very user-friendly, so we are likely to see some modifications and updates on that in the very near future as well.

The sands may yet still shift on the act’s dispute process, but otherwise, most elements of the No Surprises Act will stay intact. The patient protections from balance billing will not change, and all providers, not just those that are out-of-network, are still expected to provide good-faith estimates of services for uninsured and self-pay patients.

Programming Note: Listen to Matthew Albright’s legislative update every Monday on Monitor Mondays, 10 Eastern.