A Year in Retrospect: How the No Surprises Act Impacted Medical Billing

The Best Response to the NSA is Still a Strategic and Compliant Approach

One year ago, the United States marked a turning point for health care cost transparency with a new law aimed at helping Americans avoid unnecessary, unexpected medical debt.

The No Surprises Act (NSA) was signed into federal law after years of negotiation between health plan insurers, employers and providers. Taking effect January 2022, the NSA covers participants in employer-sponsored health plans and aims to provide protection from surprise medical bills for certain emergency services as well as services received from out-of-network providers at in-network facilities. (storeys.com)

Following is a summary of the pros and cons of the NSA to date:

The Pros

  • Experts say bipartisan support of the NSA was a rare victory for patients against exploitative health care costs.
  • The NSA now better protects the rights of patients from surprise medical bills.
  • Participants who had medical expenses subject to the NSA likely received higher benefits and had less out of pocket expense in 2022.

The Cons

  • While there was widespread enthusiasm and expectations of relief from surprise balance billing, the NSA has made very little progress since its implementation. Some claim the NSA is vague and confusing, and call for Congress to offer a solution.
  • Health plans that paid more saw the cost of coverage increase – potentially triggering an increase in the participant’s point of purchase cost sharing (deductibles, copayments, etc.) and/or an increase in all covered employee contributions in 2023 and future years.
  • The NSA is challenging providers who now face lower OON payments and IDR delays.
  • The NSA bottleneck can be attributed to a flawed and ineffective Independent Dispute Resolution (IDR), an arbitration process which ensues following the first processing of the benefit claim, followed by a period of negotiation for payment disputes and upon failure to resolve the dispute. It is clear that IDR guidance is needed, which depends upon outcome of current litigation. To the extent that the courts compare and focus on the actual statute with the agency regulations, the litigation may prompt changes in the agency regulations. 

A Strategic Solution for Health Plans

Health plans need to understand their rights under the NSA legislation and price transparency mandates designed to reveal the true cost of provider health services before receiving care and submitting a claim.

The best response to the NSA is still an approach that is both strategic and compliance oriented. Reference-Based Pricing (RBP) is one of the fastest growing solutions in health benefits cost management to avoid unreasonable or excessive provider charges – potentially lowering the cost of coverage and employee point of purchase cost sharing.

An effective way for employer-sponsored health plans to address the requirements and challenges of the NSA and IDR process is to adopt a “pure” RBP plan. These plans that do not contract with providers should remain unaffected by NSA because there aren’t any out-of-network claims; nor is there any determination of a median in-network rate.