The No Surprises Act is Full of Surprises Legislation had problems from the get-go

By LYNNE JETER

The No Surprises Act (NSA), which went into effect Jan. 1, 2022, to protect patients from an estimated 12 million surprise bills annually, has been fraught with challenges, with medical professionals calling at least one of its processes flawed and ineffective.

“While the goals of consumer protection, price transparency, and cost concessions are important and necessary, the legislation is starting to present real challenges to practices’ financial stability,” said Dan D’Orazio, CEO of Sage Growth Partners, a national consulting firm for healthcare organizations.

The NSA applies to employersponsored health plans for certain emergency services and those received from out-of-network providers at in-network facilities regarding balanced billing. The act doesn’t apply to out-of-network providers at out-of-network facilities. Providers risk a penalty of up to $10,000 per violation.

“If a patient requests it, even physician offices are required to provide a good faith estimate,” said Matt Clements, CFO of Sage Infusion, a Type 1 diabetic well-versed in clinical visits. “One day soon, upfront pricing may be a requirement for all practices.”

The Benefit Claim Process

The benefit claim process is wieldy and time-sensitive and -consuming. When negotiation doesn’t resolve the dispute, the NSA provides for an arbitration process, Independent Dispute Resolutions (IDR).

The Centers for Medicare and Medicaid Services (CMS) anticipated 22,000 IDR appeals in 2022. Yet within the first six months of the law going into effect, more than 90,000 IDR appeals were initiated. What’s more, only 3,500 determinations had been made by mid-December.

The Trouble with IDRs

Under the IDR process, a strictly controlled baseball-style arbitration for disputing unreasonable reimbursement amounts with insurers, a provider must initiate open negotiations within 30 days of receipt of the payment or notice of denial.