As a leading national medical group, Envision Healthcare strongly supports the intent of the bipartisan No Surprises Act (NSA) that went into effect last year. Taking patients out of the middle of billing disputes between providers and payers was the right thing to do.
The critically important patient protections are the heart of the law. However, the provisions of the NSA that ensure fair reimbursement for clinicians are equally crucial to maintaining a functional healthcare system – and avoiding any unintended impact to patients.
The NSA was supposed to make it easier to resolve billing disagreements between clinicians and insurers – while holding patients harmless – through a balanced Independent Dispute Resolution process. However, it’s clear that some insurance companies are abusing the process for their own financial gain. At every turn, insurers have attempted to capitalize on loopholes, create confusion, and make it harder for clinicians to obtain fair payment for the medical care they’ve already provided. Health insurers’ sabotage has resulted in a dispute resolution backlog more than 6 months long.
Envision Healthcare is committed to being part of the solution. The stakes are simply too high for the patients our clinicians proudly care for each day in local communities. Fortunately, the solutions we’ve proposed are straightforward and relatively simple to implement. They focus on closing the loopholes that insurers are abusing and holding bad actors accountable.
Over the past several months, Envision Healthcare has laid out a roadmap to implement the NSA in a more balanced way. We have communicated that roadmap to CMS. These efforts are guided by our strong commitment to ensuring that patients benefit from the NSA – without risk to access – as was intended by the legislation.
Our solutions-based approach includes these recommendations:
- HHS should unify the dispute process under a single federal portal. This single point of access should be the start and end points for resolving disputes, from the Open Negotiation process through IDR award determination. Updates to this portal should occur at regular and predictable intervals or only when substantial (or cumulatively substantial) improvements are being made. Changes should be previewed with the stakeholder community and comments on their impact, value, and approach should be taken into consideration.
- HHS should engage in audits of the Qualified Payment Amounts (QPA) that appear to be inconsistent with statutory intent. This would help end health insurers’ ability to systematically underpay providers through bad faith distortion of reimbursement and contract data. HHS has already acted to address the “ghost rates” loophole, which allowed insurers to calculate unreasonably low QPAs in a way never intended by Congress or regulators. Insurers shouldn’t be trusted to suddenly act in good faith. Audits should also examine whether the methodology for calculating the QPA results in amounts that are relatively in line with actual median in-network payments.
- HHS should require insurers to use already existing Remittance Advice Remark Codes (not proprietary payer codes) to designate the correct venue for dispute resolution at the time of the remittance or notice of denial. Despite the availability of these codes – and the fact that insurers have all the information necessary to know exactly which codes are most appropriate – they have chosen to use ambiguous and non-specific codes that intentionally create confusion. This deliberate obfuscation has resulted in thousands of claims being incorrectly submitted to the federal arbitration system. HHS has attempted to “strongly encourage” plans to use the most appropriate codes without success.
- Insurers don’t provide clinicians with the information they need to distinguish between self-funded and fully-insured plans for the purposes of batching. HHS should modify requirements for the submission of data included in electronic remittance advice to include clear designations of plan types and uniformity in identifying individual self-insured plans.
Each of the above recommendations would have an immediate and meaningful impact on the enormous administrative burden currently faced by clinicians, arbiters, and HHS. They would ease the strain on the IDR process and begin to chip away at the significant backlog that has plagued the process since day-one. Just as importantly, these recommendations would reduce waste within the healthcare system, allowing more resources to be spent on the provision of care instead of navigating an administrative morass created by bad actors in the insurance industry.
We appreciate the work that HHS and other federal departments have done to address NSA implementation challenges that have already been identified. We will continue to actively engage with HHS as we work toward our shared goal of securing the intended patient benefits of the NSA.