GAO: No Surprises Act rollout has been ‘challenging’ for radiologists, other physicians

The rollout of the No Surprises Act has been “challenging” for radiologists and other physicians, according to a new report from the U.S. Government Accountability Office released Tuesday.

Federal departments had anticipated only about 22,000 disputes between commercial insurers and providers in 2022. However, between April 2022 and June of this year, the actual number was more than twentyfold higher—at 490,000. About 61% of such quarrels over payment for out-of-network care remained unresolved at the time of the analysis.  

“The groups GAO interviewed described a challenging rollout of the independent dispute resolution process, including a higher-than-expected dispute volume,” the office noted. “Four groups told GAO the departments did not account for the experience of states with similar processes when making the estimate. Disputing parties and certified entities also described the broader effects of those challenges, such as backlogs resulting in delays in payment determinations.”

The 2021 law prohibits the sending of “surprise” medical bills to patients for some healthcare services. It aimed to address this issue by launching a voluntary forum to help determine how much insurers should pay for care that falls out of a consumer’s health plan network. The process became effective in April 2022, GAO noted. Complexity of determining whether disputes are eligible for the arbitration process is a “primary cause” of the large number of unresolved disputes, according to the report.

CMS and the Department of Labor have attempted to investigate these complaints. However, stakeholders continue to express concern with the poor response to these challenges and the hefty fee providers must pay to participate in the arbitration process. Some specialties, including radiology, may not be able to overcome the $350 charge, with certain services having claim amounts below that threshold.

“The departments reported limited ability to increase enforcement efforts due to budget constraints,” the GAO noted. “HHS has requested a budget increase for the process, and the departments are revisiting the administrative fee amount, which is intended to cover the costs of the process, and plan to issue updated program rules.”

Over 75% of out-of-network disputes have involved emergency services, with “ancillary” services such as radiology, anesthesia and pathology making up the balance.

GAO also explored private equity’s role in contributing to the dispute backlog. The office found that 6 of the top 10 initiating parties submitting disputes were owned, at least in part, by private equity firms. These parties accounted for 46% of all out-of-network disputes submitted in 2022.

They included Singleton Associates, a Texas-based practice that is part of Radiology Partners. The group submitted 6,048 disputes last year, or about 3% of the total pie. Sonoran Radiology, a second RP practice that’s based in Phoenix, also made the list, submitting 4,693 disputes (or 2%). Singleton Associates has been involved in a heated dispute with UnitedHealthcare over alleged underpayment. Sonoran Radiology, meanwhile, announced an in-network agreement Blue Cross and Blue Shield of Arizona in May.

The report is no surprise to imaging industry watchers who have followed the No Surprises Act rollout. Advocacy groups such as the Radiology Business Management Association and American College of Radiology have previously raised issue with some of the challenges unearthed by the office.

“The recently issued GAO report provides further evidence that the NSA is unworkable for physicians and patients. Congress, the courts and now GAO all agree that the NSA implementation needs to be addressed and corrected,” RBMA Executive Director Bob Still told Radiology Business Wednesday.

The Consolidated Appropriations Act of 2021, which established the NSA, included a provision for the GAO to review the dispute-resolution process. To reach its conclusions, the office reviewed published reports, relevant federal laws, regulations and guidance. It also interviewed officials with CMS, Labor and five healthcare providers.