ACR Challenges Health Affairs Study Claims on NSA Dispute Costs

A recent Health Affairs Forefront article regarding the No Surprises Act (NSA) Independent Dispute Resolution (IDR) process raises important questions about healthcare spending. However, IDR case volume and provider success rates are driven by insurers’ refusal to negotiate reasonable in-network rates, meaningfully participate in open negotiations, and adjust IDR offers. This pattern continues despite arbiters and courts ruling that the insurers’ non-transparent offers based on the disputed Qualifying Payment Amount (QPA) do not reflect real-world medical practice. 

Insurers are narrowing their networks - not providers. Blue Cross Blue Shield of NC, BC/BS of TN and CIGNA of TN all cited the No Surprises Act when demanding providers either accept drastic reimbursement cuts or risk termination of their contracts. Providers often report increasingly low out-of-network payments and in-network contract offers, leaving arbitration as the only practical path to fair reimbursement.

In addition, the opaque, solely insurer-defined QPA is increasingly disconnected from market reality. The Fifth Circuit Court of Appeals recently ruled that key aspects of the federal QPA calculation methodology are unlawful and found that the inclusion of certain non-negotiated rates resulted in artificially low payments.  For example, in their QPA calculations, insurers frequently include lower primary care provider contract rates for specialty services that were never offered or performed by those practices. In fact, insurers initially offered zero dollars or a nominal amount in up to 25% of IDR cases. The pending No Suprises Act Enforcement Act seeks greater transparency in insurer rate-setting and stronger enforcement against insurers that do not promptly pay binding arbitration awards.

The government put guardrails in place when initiating the IDR process to protect against payers' unsubstantiated claims of arbiter shopping. Medical providers cannot pick arbiters over insurer objections. A provider or an insurer may initiate a dispute and select a certified arbitrator, but the opposing party has the right to object. If the parties cannot agree, the federal government assigns the arbitrator. This prevents either side from steering cases to preferred decision-makers.  Arbitrators simply apply the law as written, which prohibits reliance on heavily discounted benchmarks such as Medicare rates and limits the weight given to the insurer-generated QPA.

Radiology out-of-network (OON) care is not driving increased insurance premiums or patient costs. Ninety-nine percent of radiology reimbursement claims are in-network. In addition, overall medical imaging costs and utilization have gone down over the last two decades.

As evidenced by court decisions, disputed claims arbitration results, and efforts by insurers to force radiologists out of their networks, healthcare providers are not the problem. Policymakers should work with providers and insurers to consider relevant and verifiable data, guarantee adequate provider networks, and protect access to care by ensuring sensible, sustainable reimbursement.