The federal No Surprises Act may have been a good idea on paper, but it has turned out to be difficult to implement. More than 6 in 10 of 490,000 submitted disputes had not been resolved as of June, according to a new Government Accountability Office report.
The No Surprises Act directed the departments of Health and Human Services, Labor and Treasury to establish a federal independent dispute resolution process. This process, which became effective in April 2022, is a voluntary forum for health care providers and insurers to resolve disputes about how much should be paid for out-of-network care. Certified dispute resolution entities, which serve as arbiters, make payment determinations.
The GAO reviewed published reports, relevant federal laws, regulations and guidance, and interviewed officials from the Centers for Medicare & Medicaid Services and the Labor Department. It also interviewed five selected health care providers or their representatives, which accounted for nearly half of all submitted disputes as of December 2022. In addition, GAO interviewed three issuers, three certified entities that arbitrate the disputes and 10 stakeholder groups.
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According to officials from the departments, a primary cause of the large number of unresolved disputes is the complexity of determining whether disputes are eligible for the process. Several stakeholders described a challenging rollout of the independent dispute resolution process, including a higher-than-expected dispute volume.
For example, the departments anticipated about 22,000 disputes in 2022 but received nearly 490,000 through June 2023. Four groups said the departments did not account for the experience of states with similar processes when making the estimate. Disputing parties and certified entities also described the broader effects of these challenges, such as backlogs resulting in delays in payment determinations. The departments have taken some actions to address challenges, such as conducting pre-eligibility reviews on submitted disputes.
Stakeholder groups also expressed concern with what they describe as a lack of response to submitted complaints. The departments reported limited ability to increase enforcement efforts because of budget constraints. HHS has requested a budget increase for the process, and the departments are revisiting the administrative fee amount, which is intended to cover the costs of the process, and plans to issue updated program rules.
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Alan Goforth
Alan Goforth is a freelance writer in suburban Kansas City. In addition to freelancing for several publications, he has written a dozen books about sports and other topics.
