News: Health insurance companies renege on No Surprises Act in bad faith, survey suggests

August 17, 2023

CDI Strategies - Volume 17, Issue 33

Health insurance companies have been violating and back-tracking on their legal commitments to the No Surprises Act (NSA), according to HealthLeaders.

The NSA was passed by Congress in order to protect patients from unexpected gaps in their health insurance coverage while also maintaining their access to quality care. Accordingly, Congress established a dispute resolution framework for out-of-network care that removes patients from reimbursement disputes between insurance companies and medical providers.

However, payers have been unwilling to pay.

A new study conducted by the Americans for Fair Health Care (AFHC) advocacy organization, surveyed 48,005 clinicians in 45 states across specialties ranging from anesthesia to obstetrics, to urgent care; it also surveyed across the size of the care practice (24.5% small, 28.9% medium, and 46.5% large), and community type (15.2% rural, 8% exurban, 37.8% suburban, 39% urban).

The survey found payers have been engaging in a number of bad faith actions, which violate the spirit and letter of the NSA. Here are the key findings from the survey:

36% of in-network contracts have been terminated, with payers citing NSA as the reason.
100% of providers have been threatened with contract termination 16 times, on average.
81% of providers have had at least one contract terminated by a payer.
On average, these providers have had nine contracts terminated by payers.
On average, payments were cut 52% after payers terminated in-network contracts.
94% of providers have received Qualified Payment Amounts (QPA) payments priced at or below Medicare rates.
100% of providers have received take-it-or-leave unilateral contract amendments.
On average, insurers have made take-it-or-leave demands 11 times to providers.
After IDR, 52% of payments determined by IDREs were not made at all (zero payments).
Among payments made after IDR determination, 49% were not made in the required 30-day timeframe, and 33% were made in an incorrect amount.
Only 5% of disputes, on average, have been resolved during open negotiations.
Payers have made an open negotiations counteroffer only 26% of the time.
Payers disclose which claims are federal IDR-eligible only 33% of the time.
Once in the IDR process, it takes an average of 119 days to resolve disputes.
QPAs have been machine-readable only 64% of the time.
On average, it has taken 236 days overall for a payment dispute to be resolved and paid.
Only 24% of IDR submissions are completed—an average of 67% remain pending.