AMA, providers seek stricter enforcement of No Surprises Act

Healthcare providers are asking lawmakers to put more pressure on payers to comply with the No Surprises Act.

Payers aren't abiding by the law's payment requirements when providers prevail in the independent dispute resolution, or IDR, process, the American Medical Association, 50 state medical societies and 45 healthcare groups wrote in a letter to congressional leaders on Tuesday.

The organizations said that payers continue to bill patients improperly, delay payments beyond the law's 30-day timeframe and, in some cases, refuse to pay altogether. Physician practices end up absorbing unpaid costs and payment delays while waiting on the funds they are legally entitled to, they continued.

Stricter enforcement of IDR rules is needed to bolster implementation of the No Surprises Act, the letter stated.

The organizations backed a bipartisan, bicameral bill called the No Surprises Act Enforcement Act (H.R. 4710/S. 2420). The bill would require payers to comply with IDR payment requirements and impose penalties if they fail to pay providers within 30 days.

It would also impose interest charges on unpaid amounts when payers do not pay on time.

The organizations explained in the letter that the No Surprises Act Enforcement Act and similar legislation are needed to bridge the "enforcement gap," which has rendered IDR process improvement efforts meaningless since payers continue to ignore payment determinations.

The legislation would "restore balance achieved by the statute and ensure accountability," they said.

The organizations also advocated for greater transparency and enhanced guidance to improve the IDR process. For example, they supported proposals to identify eligibility in initial remittance advice from payers to providers to address what payers have called a flood of ineligible claims into the IDR system.

Payers have even sued hospitals and other provider groups over allegedly gaming the IDR process by submitting an excessive number of claims in hopes of winning payment determinations. Providers win the vast majority of IDR cases, with rates exceeding 80%, according to Georgetown University's Center of Health Insurance Reforms.

Providers are also winning much higher payments than payers would reimburse them for care. The data also showed that the prevailing provider offer was 383% of the qualifying payment amount, which is generally the median contracted rate for a payer.

However, the AMA and other provider organizations said in an April 27 letter to leading government officials that determining claim eligibility under the IDR process remains a challenge. Payers also fail to convey when claims are eligible, even though they have that information, and oftentimes do not participate in open negotiations.

In the newest letter, the AMA and other organizations also called for formalizing the open negotiations process, which occurs before payers and providers enter the IDR process

But little action has happened with the No Surprises Act Enforcement Act since it was introduced by Congressman Greg Murphy, M.D. (R-SC), in July, alongside Representatives Jimmy Panetta (D-CA), John Joyce, M.D. (R-PA), Raul Ruiz, M.D. (D-CA), Bob Onder, M.D. (R-MO) and Kim Schrier, M.D. (D-WA).

Congressmen Roger Marshall, M.D. (R-KS) and Michael Bennet (D-CO) also introduced companion legislation in the Senate at the time.

The bill has been referred to specialty committees since its introduction, so no vote has been scheduled.

Still, the AMA is one of the most powerful healthcare industry lobbying forces, touting an "aggressive legislative advocacy effort." The group, along with medical societies and healthcare groups, remains committed to passing the bill to ensure the successful implementation of the No Surprises Act, including "achieving the balanced framework Congress intended," the letter stated.

"Our organizations remain fully committed to the core purpose of the No Surprises Act: protecting patients from surprise medical bills while ensuring physicians and other healthcare providers receive fair and timely payment for the medical services they provide," the organizations said.

Jacqueline LaPointe is a graduate of Brandeis University and King's College London. She has been writing about healthcare finance and revenue cycle management since 2016.