The No Surprises Act, aimed to protect patients against balance billing and create cost transparency, took effect Jan. 1, 2022, and the law has shifted how many physicians and ASCs provide care.
Here are 10 things to know about the bill one year after it took effect:
1. HHS and the Labor Department Aug. 19 issued the final rules for the No Surprises Act. Here are three changes that ASCs need to know, which update the definition of "downcode" and the independent dispute resolution process.
2. A report from AHIP and the Blue Cross Blue Shield Association found the bill has saved 9 million patients from surprise medical bills since January 2022. A separate study found the act could result in 3 million more emergency room visits each year, because individuals no longer fear catastrophic bills.
3. The Medical Group Management Association, which represents more than 15,000 medical groups comprising more than 350,000 physicians, penned an Aug. 2 letter asking CMS to give physician groups at least six months' notice before the enforcement of any more surprise billing requirements.
4. Litigation over the act has centered on the arbitration process. The Texas Medical Association filed its third lawsuit challenging the act on November 30. In a news release, the association said it was challenging rules that "skew negotiations in favor of health insurers so strongly that health insurers will force physicians out of insurance networks and physicians will face significant practice viability challenges, struggling to keep their doors open in the wake of the pandemic."
5. In October, the American Hospital Association and the American Medical Association, along with 30 additional national and state medical groups, filed amicus briefs supporting the Texas Medical Association's second lawsuit.
6. The act is hurting anesthesia reimbursements, leaders say. Adam Spiegel, CEO of Irving, Texas-based NorthStar Anesthesia, told Becker's the bill is making it difficult for anesthesia providers to secure reimbursements.
"The biggest challenge to securing anesthesia reimbursement in 2023 is the impact of the No Surprises Act," he said. "The act has tilted the scales in contract negotiations in favor of payers, making it difficult to predict future payment amounts and driving a trend of lower reimbursements in a period of increased costs of doing anesthesia. The lack of visibility into future rates is incredibly challenging in our relationships with our hospital and ASC partners."
7. Other ASC and surgery leaders also feel the act is favorable for payers, rather than patients or providers.
"The No Surprises Act, while it was a very good piece of legislation, has been asymmetrically applied to favor the insurance companies," Brian Gantwerker, MD, spine neurosurgeon at the Craniospinal Center of Los Angeles, told Becker's. "I think what's really fearsome is that the bureaucracy within the Centers for Medicare just seems to be either tone-deaf or willfully ignorant of what's really driving the cost of care. That's really scary because over 110,000 physicians left the practice in 2021 — that should give pause to everybody, and I don't think you can grow physicians fast enough to really take up that gap."
8. Many leaders specifically cite the act's independent dispute process as an obstacle. Providers are concerned about the weight given to the qualifying payment amount, the median contracted amount for the service, during the independent dispute process, Tony Mira, CEO of Anesthesia Business Consultants, wrote in an August blog post. Providers are concerned the policy will incentivize payers to lower rates for in-network services.
9. HHS has received more than 90,000 claims since launching the independent dispute resolution portal in April. A CMS spokesperson told Bloomberg Law that figure is "substantially more than the department initially estimated would be submitted for a full year."
10. Nearly 70 percent of the No Surprises Act independent dispute resolution cases that have been closed were deemed ineligible for the process. Between April 15 and Sept. 30, 2022, there were 90,078 disputes initiated, according to a CMS report. Of those cases, 23,107 have been closed. A payment determination was reached in 15 percent of cases, and disputes were closed in 69 percent of cases because they were found to be ineligible for the process.