Something for us to keep in mind as we go through the GAPBAC process and efforts to potentially use arbitration as a solution….

---------------------

Docs say insurers ignore surprise billing decisions

Tina Reed

August 3, 2023

https://www.axios.com/newsletters/axios-vitals?id=2

Insurers are sometimes ignoring rulings to pay providers, or failing to pay them in full, under the arbitration system established by the new federal surprise billing law, providers tell Axios.

Why it matters: The No Surprises Act, a bipartisan effort to limit unexpected out-of-network medical bills, required that insurers and providers undergo an independent arbitration process to settle their differences without involving patients. The complaints from providers are the latest snag with the arbitration system that launched last year.

Driving the news: Some providers say they received letters from insurers explicitly saying they won't honor an arbitration award because they view them as "unenforceable" and "not binding," according to the Americans for Fair Health Care, a coalition of clinical and advocacy organizations.

• The leading trade groups representing doctors and hospitals also said they've heard complaints from their members about not receiving arbitration awards. "This undermines the careful balance Congress struck in the No Surprises Act and threatens to destabilize already financially strapped providers," said Molly Smith, vice president of policy for the American Hospital Association.

The other side: Insurers have said providers are bogging down the arbitration system with frivolous challenges to billing decisions. They also say arbitrators are bundling multiple decisions together in a way that's contributing to administrative delays.

What they're saying: The Centers for Medicare and Medicaid Services and other federal agencies regulating surprise billing have received a number of complaints regarding late payments following arbitration, a CMS spokesperson confirmed.

• The agency "is actively investigating and addressing complaints regarding late payments," the spokesperson said, adding the statute is clear that the arbitration process is binding unless there is evidence of fraud.

What we're watching: Whether CMS will make further changes to the arbitration process in response to providers' complaints — or whether litigation challenging that system, such as one lawsuit from the Texas Medical Association, may force the agency's hand.