Healthcare Affordability: Dispute ­­Resolution Pathways Under the No Surprises Act

In the complex world of U.S. healthcare, the vast chasm between care costs and patient’s ability to afford them continually widens. According to the United States Census Bureau, 8.6% of adults were uninsured in 2021, making an extensive population vulnerable to excessive healthcare expenses. The healthcare affordability crisis is reflected in a YouGov 2022 study, revealing that 49% of Americans can’t afford surprise bills over $400. Many insured individuals struggle with out-of-pocket medical costs, averaging $1,763 in 2022 (Statista).

The No Surprises Act protects patients from unexpected medical expenses by establishing a dispute resolution mechanism. Patients can dispute surprise medical bills that exceed $400 from the Good Faith Estimate (GFE) using the Patient-Provider Dispute Resolution (PPDR) process. Providers can use the Federal Independent Dispute Resolution (IDR) process to request additional reimbursement from payers who are negotiating lower contracted rates.

Empowering Uninsured Patients Against Unexpected Bills

Uninsured or self-paying patients can use the PPDR process to challenge medical bills exceeding their GFEs by $400 or more. A $25 fee is charged to initiate a dispute, refunded by the provider if the patient prevails. Patients can resolve disputes amicably with providers, leading to bill reductions or full payment agreements. If no agreement is made, a Selected Dispute Resolution (SDR) entity is selected and intervenes.

A patient has 120 days from receiving the bill to initiate a dispute through the U.S. Department of Health and Human Services (HHS). Upon paying the administrative fee, the SDR entity verifies eligibility for the PPDR process within three days. If additional information is required from the patient, they have 21 calendar days to provide it. The provider has ten days to submit their documentation supporting the additional charges as unforeseen. The SDR entity reviews each charge not listed in the GFE and determines the payment, favoring the lesser billed charges or the median health plan payment for the same services.

Understanding Dispute Resolution for Insured Patients

The IDR process resolves billing disagreements related to out-of-network care costs for insured patents. Between April 15, 2022, and March 31, 2023, the IDR process handled 334,828 disputes, with initiating parties prevailing approximately 71% of the time. These statistics reveal the significance of the IDR process, where disputes over lower reimbursement are increasingly common.

The IDR process applies to disputes related to emergency services, non-emergency items and services provided by out-of-network providers at certain in-network healthcare facilities, and air ambulance services. It applies to self-insured plans sponsored by private employers, private employee organizations, and the Employee Retirement Income Security Act (ERISA) in all states, with a few exceptions.

Before initiating the IDR process, an initial payment or denial notice is sent within 30 calendar days of receiving a clean claim, followed by a 30-business-day open negotiation period. Either party can initiate the IDR process within four business days of ending the open negotiation period. Both parties must submit their offers within ten business days and pay the required fees. The IDR entity then determines the payment within 30 business days.

Certified IDR entities, listed on the CMS website, charge $350-$700 for a single determination and $475-$938 for a batched determination. Both parties pay a $350 non-refundable administrative fee and the IDR entity before the IDR entity begins reviewing their offers. The prevailing party will receive a refund of the IDR entity fee. Violations can be reported to the No Surprises Help Desk at 1-800-985-3059.

Strategies to Avoid Disputes

To mitigate disputes and enhance the healthcare experience, healthcare providers can adopt some strategic standards.

1. Create Accurate GFEs: Providers can leverage data from past claims to create precise GFEs. Requesting the HCPCS/CPT code from payers ahead of time can assist in verifying the intended procedure, increasing GFE accuracy.
2. Employ an NSA Expert: An employee with an in-depth understanding of the NSA can be an asset. This expert should be skilled in negotiations as they can effectively facilitate communication between the parties involved, potentially avoiding a dispute.
3. Be Proactive: When the charged amount exceeds the GFE by $400, the provider’s representative can then reach out to the patient, clarify the reasons for the additional charges, and work out a viable payment arrangement. Additionally, the GFE and final bill should include the contact details of the facility, preferably an individual or department extension.
4. Utilize NSA tools: Dedicated tools like CorroHealth’s NSA tool can be invaluable to streamline GFE creation processes, helping healthcare organizations adhere to NSA regulations. With the automation of calculations for GFEs for both the uninsured and attached to the Notice and Consent for an insured individual who agrees to be balance billed when it’s not prohibited, healthcare providers can equip patients with the necessary tools to make informed choices, understand their potential healthcare costs and minimize unexpected medical bills.

Upholding compliance and patient-centric values fosters transparency, cultivating trust between patients and healthcare providers. Building trust can help avoid disputes over medical bills. As we navigate the course set by the No Surprises Act, our collective goal remains the evolution of a healthcare system that prioritizes patient needs at an affordable price.

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