How Employers Who Sponsor Health Plans Can Avoid No Surprises Act … “Challenges”

As federal health initiatives go, the botched rollout of the No Surprises Act (NSA) Independent Dispute Resolution (IDR) process almost rivals that of Health Reform. Just one decade ago, on October 1, 2013, the website went live, and crashed within two hours after successfully registering 26 people across the entire United States population – ONLY 26!

For comparison, during the period April 15, 2022, through June 30, 2023 (the first 15 months), the NSA IDR process received nearly 490,000 arbitration requests – compared to the 22,000 disputes CMS/HHS expected in 2022! Over 60% of those requests remain unresolved.

The Government Accountability Office (GAO) recently released its report following a review of the IDR process. GAO examined the number and types of disputes submitted between April 2022 and June 2023, stakeholder experience with the process, agency oversight, agency actions and the widespread lack of resolution.

The IDR portal initially opened April 15, 2022, and due to issues and litigation, it has closed and reopened more than once. Most recently, it reopened on December 15, 2023.

NSA Requirements

The No Surprises Act (NSA) was enacted in December 2020. The NSA established various consumer protections related to surprise billing—i.e., circumstances where individuals receive “balance bills” because provider fees exceeded the eligible medical expenses per terms of the employer-sponsored medical plan. NSA requirements are generally limited to those services provided by out-of-network providers delivering emergency services or delivering non-emergency services at in-network facilities.

Had Enough?

Most plan sponsors took a “compliance only” approach in amending their plan for the NSA and failed to reconsider their coverage strategy. Implementation reminded us of Health Reform – where plan sponsors, with a shrug of the shoulders would ask: “Well, what do we need to do … now.”

If you decided on a compliance-only approach, you are spending more in at least two ways:

    • o Certain expenses that would have been processed using separate out-of-network cost sharing are now treated under in-network rules, and
    • o You are paying for added administrative expenses, including but not limited to determining the Qualified Payment Amount (QPA), processing IDR requests, etc.

Those increased expenses are real – whether or not your management reports itemize the changes.

The best response to the NSA is the same as it was for Health Reform – deploy both strategic and compliance-oriented responses. It is never too late to shift from a compliance-only approach.

Value of a Medical Billing Partner

Plan sponsors are benefiting from strategic actions that deliver a competitive financial advantage – such as medical billing partnerships that provide them with insight and data-driven solutions. Harnessing technology to understand the vast amount of data can identify potential areas of escalating health costs and identify opportunities to control medical spending. Innovative medical billing services utilize powerful data-driven software and online data analytic tools that can provide a degree of price transparency and new insights by harnessing price data electronically – allowing fee comparisons that identify fair and reasonable prices. This type of support had not been readily available to the self-insured community – which is growing rapidly and now includes 65% or more of health plan participants among US companies of all sizes.

The right medical billing partner can facilitate strategic designs and processes – acting as an agent of change, embracing technology innovation and advocating for “what is fair and just.” The right partner will also provide value-added services through turnkey solutions, innovative plan designs, administrative and compliance support as well as participant legal representation.

What Now?

The best solution? To lower the cost to plan sponsors AND plan participants while resolving the challenge of “balance bills,” an ever-increasing number of small and mid-sized employers have adopted various forms of Reference Based Pricing (RBP) coupled with robust legal and advocacy services.

In the past, most plan sponsors limited the application of RBP to out-of-network providers. Today, increasingly, plan sponsors are eliminating their networks and applying RBP to all providers; or limiting networks to primary care, direct contracting and/or Centers of Excellence.

RBP coupled with robust legal and advocacy services is a scalable solution. It is best positioned alongside Health Savings Account capable coverage. And, because this solution has yet to be widely adopted, plan sponsors can still achieve a competitive cost advantage where implementation occurs in 2024!