No Surprises Act Shortcomings: ACEP and EDPMA’s Joint Letter
It is encouraging to see ACEP and EDPMA come together to express the shortcomings of the NSA implementation. In a letter to HHS, Labor, and Treasury departments, they outlined three overarching recommendations: increase enforcement at each step of the dispute resolution process, hold health insurers accountable, and improve accessibility for all healthcare providers.
This article from the ACEP details the contents of their letter. They discuss the lack of enforcement of both statutory and regulatory requirements at each step of the process, which has contributed to these ongoing issues. For example, QPAs currently lack standardization which contributes to inaccurate calculations.
ACEP & EDPMA’s 3 Recommendations
To address this issue, the joint letter from ACEP and EDPMA recommends a threefold approach: increase transparency around QPA calculation, increase auditing of the QPA, and modify the calculation methodology to ensure QPA reflects actual market rates. This threefold approach will help healthcare providers align QPA rates across the country while the auditing will hold health insurers accountable for sticking to the proper calculation methodology.
Another prominent issue is the lack of accountability to which health insurers are held. Many healthcare providers have said that during the open negotiation phase of the dispute resolution process, health insurers are not coming to an agreement prior to the IDR process, which is counter to the overall intent of the NSA. Initially, the IDR process was meant to be a last resort.
In addition to the lack of accountability pre-IDR, health insurers are not paying the amount owed post-IDR. Specifically, one provider noted that it has not received payment related to over 90% of the cases in which the IDR entity ruled in its favor. ACEP and EDPMA’s recommendation to fix this issue is to enforce required participation by health insurers and enforce required payments by penalizing health insurers’ payment failure.
The third outlined issue is the lack of accessibility to the process for all healthcare providers. The high cost of the process and backlog of claims have billing companies urging smaller physician groups to not use the process at all, due to risk of going out of business – essentially pricing out small providers. The letter from ACEP and EDPMA recommends reducing IDR fees to limit the financial burden that prevents physician practices from participating.
ACEP and EDPMA’s joint letter highlights the key shortcomings of the NSA implementation and offers a few recommendations. It is now up to CMS to consider these recommendations when implementing its rules.
In the meantime, we can help physician groups recover revenue using Allia Group’s unique litigation model.