The federal No Surprises Act was designed to prevent unexpected large, unaffordable medical bills being dumped on patients after the fact and requires healthcare providers to supply an estimate of what the care episode will cost. However, some insurance companies have used the act as a way to threaten providers with excluding them from insurance plans unless they accept lower rates. The American College of Radiology is asking providers to contact them so these incidents can be documented to build a case against these companies.
"The problem with medical billing law is really in many ways a Trojan horse. The law is being used by some insurers to push through some policies that allow them to reduce reimbursement to hospitals and physicians benefiting the insurance company, but at the expense of the hospitals, physicians and the patients they take care of. This is completely unrelated to the issue of surprise medical billing," explained Richard Heller, MD, RSNA Board member, associate chief medical officer for health policy and communications, and national director of pediatric radiology at Radiology Partners. He spoke with Radiology Business on this issue at the Radiological Society of North America 2023 meeting.
He said insurance companies are putting these new payment policies in writing and sending them to radiologists at in-network practices. Heller said some insurers sent letters to practices claiming that, because of this law, if they did not accept a rate reduction, they'd be kicked out of the network.
Surprise medical billing can only take place if a physician is out of network. But Heller said insurance companies cannot threaten to boot out-of-network doctors from its network, so they are attempting to leverage the law and its potential costs on their own in-network members.
"The act is now incentivizing insurance companies to go to in-network groups and tell them to take a rate reduction or they will kick them out of network, pushing medical practices and the patients they care for out of network. This can impact patients' access to high quality, in-network radiology care," Heller said.
ACR wants to document cases of inappropriate insurance policies
Heller said the ACR is now documenting examples of this policy so they can be used as evidence when discussing the law with policymakers and insurance providers. He added that documentation also may help practices who decide to bring litigation against bad actors.
"If you see this inappropriate, irresponsible, aggressive behavior from these commercial insurers, you should speak to your lawyers for counsel. I would also encourage them to reach out to the American College of Radiology and find ways to submit the evidence to document this," Heller explained.
Having documentation will help ACR and other organizations lobby for changes to the law or other protections against these types of corporate policies.
The intent of the No Surprises Act
The No Surprises Act protects people covered under group and individual health plans from receiving surprise medical bills when they receive most services from out-of-network providers at in-network facilities. It also establishes an independent dispute resolution process for disagreements between plans and providers.
Starting in 2022, new protections were added that prevent surprise medical bills from private health insurance. If a patient is uninsured or decides not to use their health insurance for a service, under the protections of the act, they can often get a good faith estimate of the cost of the care up front, before their visit. If the patient disagrees with the bill, they may be able to dispute the charges.
Heller said the idea of the act was supported by the ACR and many other healthcare organizations and viewed as a positive move to help patients.
"If you are in a car accident and taken to a hospital, it is likely that hospital might not be in your network. It is not your fault; they took you to a hospital and did not have a choice. Or you go to an in-network hospital, but the radiologist is out of network. How would a patient know that? So, the law was created to protect patients from these surprise medical bills for out-of-network medical care," Heller explained.
How insurance providers are leveraging the No Surprises Act to lower payment rates
This issue was outlined in detail in an ACR Bulletin in November 2022. The act holds patients harmless, which means it removes them from reimbursement disputes between insurers and providers. To resolve these disputes, the law created a provider-insurer arbitration process called independent dispute resolution. IDR is used by providers who believe the amount of reimbursement they received from the payer was not sufficient. If the provider and insurer are unable to come to an agreement, the situation may move to arbitration.
The administration in rulemaking calls for arbiters to begin with the presumption that an insurer-determined rate, termed the qualifying payment amount, is appropriate, unless there was evidence to the contrary. This rule created a “rebuttable presumption,” ignoring the law’s intent that the QPA be among equally weighted factors considered in these disputes, Josh Cooper, ACR vice president of government relations and economics health policy, explained in the bulletin. Questions over this rule were the subject of the two lawsuits filed by the Texas Medical Association. They won the suits because this language is not in the law, therefore the administration cannot mandate it.
He said the rule made the QPA the primary factor, creating a benchmark payment set by insurers. This has resulted in some insurance companies demanding lower rates from its network physicians, a situation radiologists say could result in narrower provider networks, drastic imaging reimbursement cuts regardless of network status, and potentially reduced access to care for patients.
Dave Fornell has covered healthcare for more than 17 years, with a focus in cardiology and radiology. Fornell is a 5-time winner of a Jesse H. Neal Award, the most prestigious editorial honors in the field of specialized journalism. The wins included best technical content, best use of social media and best COVID-19 coverage. Fornell was also a three-time Neal finalist for best range of work by a single author. He produces more than 100 editorial videos each year, most of them interviews with key opinion leaders in medicine. He also writes technical articles, covers key trends, conducts video hospital site visits, and is very involved with social media. E-mail: dfornell@innovatehealthcare.com