A Thumb on the Scale – The No Surprises Act’s Unfair Bias Towards the Insurance Industry

bias towards insurers

Since the conception of the No Surprises Act, concerned physician groups and advocacy efforts have centered around the fact that the law and its IDR process “place a thumb on the scale in favor of insurers.” Even with a final ruling in place to assuage these concerns, there are still issues surrounding the laws and their biases towards insurers. Below, find a collection of articles about the leverage health insurers use to underpay providers and financial proof of their unfair advantage, facilitated by details of the No Surprises Act.

This comprehensive piece from Bloomberg Law provides a legal breakdown behind the NSA. As the act inches closer to its first full year as a law, they identify its rocky start and the incomplete implementation of its regulations, leading up to the final ruling released on August 26th, 2022.

The NSA’s shortcomings and its independent dispute resolution process (IDR) was meant to be an even tool for providers and plans alike to dispute underpayments, but its design is biased towards insurers.

According to the authors, “Some providers report that they are not receiving initial payments within the required time frame or they are receiving the initial payments without the required qualified payment amount information.”

The consistent theme is that carriers are not providing the QPA which is required to begin IDR. Even further, the QPA value is generated entirely through use of insurer data, leading to controversy around the manipulation of these values.

It’s been a challenging year for US hospitals and health systems, according to Healthcare Dive. In strong contrast, health insurance companies including Cigna and United HealthCare are experiencing climbing profits, even as their members’ medical spending and usage decline.

Underlying the insurers’ profits is their underpayment of health care providers balanced with higher premiums. The insurers’ scale and leverage affords their position to both negotiate low in network contracted reimbursement rates and severely underpay out-of-network physicians.  

With big health insurance players reporting multi-billion dollar incomes, there is greater urgency for a novel approach to level the playing field.

Allia Group’s litigation platform and multi-provider claim bundling offers leverage to counterbalance the insurers. This yields additional revenue and improves cash flow for hospitals, physicians, and health systems.

More evidence: As a recession looms and all industries face financial threats, including hospitals’ increasing labor costs, most of the nation’s largest insurers’ profits continue to climb.

With the population facing the potential loss of insurance coverage from layoffs and fewer patients able to afford commercial insurance, this will inevitably lead to the growth of out-of-network emergent care.

Allia Group improves funding for emergency care practices and physician groups by recovering revenue lost to health insurance companies.

As of Q3 of 2022 – while healthcare provider profits declined as much as over 137% in the third quarter, payers’ revenue increased up to 70%.

Most healthcare organizations have now released their third-quarter earnings, which show a significant and ever-widening gap between provider and payer profits.

Deteriorating relationships continue for payers and providers. In 2022, BCBS and University of Mississippi Medical Center, the largest payer and hospital in Mississippi, were out of network due to a disagreement over reimbursement rates. Jackson-based UMMC is the state’s only children’s hospital, organ transplant center, and singular provider of many other services, meaning those in need have only one option for care.

Other contract negotiations have left many patients out of network. These include Illinois’ Springfield Clinic and BCBS, which have had no contract since late 2021, affecting at least 55,000 patients.

Record profits for payers and dramatically falling profits for providers are sure signs of the negative repercussions of the No Surprises Act. Beyond that, the parties’ disagreements leave patients without care.

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