Gregory N. Nicola, MD, FACR, Chair of the American College of Radiology® (ACR®) Commission on Economics, contributed this piece.
The enactment of the “No Surprises Act” (NSA) has resulted in a variety of challenges for both patients and physicians. What does that mean for the house of radiology? Who is taking action to defend both patients and radiologists?
To gain better context into where the NSA stands now, we must first examine the evolution of the ruling. Protections for consumers against surprise medical bills arose from news stories highlighting insured patients who received exorbitantly high medical bills. Several states passed laws to protect consumers from these unexpected or “surprise” bills, offering a foundation for federal legislation. Although there was a broad consensus among stakeholders to protect patients, it was a challenge to identify a means of determining the amount that insurers should pay to out-of-network providers and how that process should work. Following two years of Congressional debate and several legislative iterations, the No Surprises Act was signed into law in December 2020. The ACR and other stakeholders secured the following adjustments to the bill:
- Removal of the monetary threshold to access independent dispute resolution (IDR).
- Removal of provisions using the median in-network rates as an initial benchmark for payment.
- Insertion of language to explicitly exclude Medicare, Medicaid and workers’ compensation payment rates from consideration in the IDR process.
With these revisions, the physician community hoped the new law would ensure that consumers were held harmless from surprise medical bills and an equitable process for provider-insurer dispute resolution had been established.
However, implementation has raised many challenges and concerns among physicians related to qualified payment amounts (QPA) and the independent dispute resolution (IDR) process. The first barrier is determining eligibility of an out-of-network dispute for the federal IDR. The NSA mandates any dispute eligible for a state out of network program enter that state specific process. Given the myriad of plan types, this determination can be confusing. The next barrier is the administrative cost of the federal IDR. The federal government recently increased these costs by 600%, deterring disputes which are not worth the expense. While batching claims was implemented as a solution for efficiency of cost and time, batching restrictions have limited the effectiveness. The wait times for those who make it through the first steps have been reported as excessive in a report to congress by The Departments of Health and Human Services, Labor, and Treasury. The federal regulators have written rules which heavily favor the payors over the providers causing a cascade of subsequent lawsuits, legal decisions and regulatory rewrites which are still ongoing. Once a plaintiff makes it through these seemingly insurmountable roadblocks with a favorable decision, they are beholden to the payor they challenged for the awarded payment. All of this is thrown on top of a financially stressed health system which will waste countless hours and money navigating a bureaucratic mess instead of doing what we enjoy – taking care of patients.
How is the ACR taking action to support radiologists and patients? Continued member outreach through sources such as the Advocacy in Action e-newsletter, social media, press releases and acr.org to share the latest information on Surprise Billing updates.
From an advocacy standpoint, ACR staff has solicited membership to determine which states and/or practices are experiencing difficulties accessing the IDR process. Staff continues to monitor instances of unscheduled payer efforts to cancel/renegotiate contracts relating to the implementation of the NSA. In addition, the Harvey L. Neiman Health Policy Institute® is conducting studies to demonstrate the impact of NSA on healthcare economics.
We stand more than 140,000 physicians strong through coalition efforts with the ACR, American College of Emergency Physicians and American Society of Anesthesiologists. Together, these societies supported the Texas Medical Association (TMA) lawsuit, recently ruled in favor of TMA to strike down provisions that inappropriately slanted the IDR process toward insurance companies.
If you’re looking for a more in-depth look into the NSA, please consider viewing the Radiology Leadership Institute® Power Hour Webinar recording titled, “Don’t Be Surprised by the ‘No Surprises Act’ – Impact to Radiology Practices and What You Need to Know,” where I’m joined by several colleague experts to discuss the ruling. Additionally, we curated a list of resources to lay the foundation for understanding on this complex topic. Please utilize these free resources and share with your fellow radiologists, and stay tuned to the ACR for the latest NSA updates.