“If providers of these services start to employ consent waivers, patients could be at risk for balance billing,” stakeholders in the insurance industry claimed.

“Several informants” underlined the need to potentially expand the NSA to address services that fall outside its scope. They described instances of patients receiving balance bills for out-of-network imaging including CT, which they underwent during a visit with an in-network, outpatient provider.

“Although such bills often come as a surprise to the patient, this type of situation is not covered by the NSA,” the report noted.

Urban Institute experts anticipate that decisions over out-of-network payments and dispute resolutions will eventually begin influencing negotiations tied to in-network providers.

“Even so, the impact may not become clear until multiyear contracts come up for renewal,” Wengle and co-authors noted. “Furthermore, the impact may be focused more narrowly on the specialties most affected by surprise billing—especially emergency medicine, anesthesiology, radiology and pathology—which could in turn limit the impact on overall health costs and plan premiums.”

A recent analysis from S&P Global Ratings shows that’s already happening. Since the roll out of the legislation, commercial insurers started terminating some of their in-network contracts that involved higher-than-average reimbursement rates. The intent, analysts noted, was to use arbitration to lower reimbursement. As one example, UnitedHealthcare knocked multispecialty provider group Envision Healthcare out of its network at the end of 2020 following the NSA’s passage, citing “egregiously high rates.”

Industry giant Radiology Partners has about 5% of its business out-of-network, while fellow private equity-backed operator US Radiology Specialists is at 1%, and there is “some risk that this percentage could increase,” S&P speculated.

Rad Partners has been submitting out-of-network claims to the independent dispute resolution process, and it’s won about 85% of the resolved cases. Yet, only 15% of the submitted claims have actually been resolved. That’s because the IDR process is running “very slow,” taking more than 250 days to settle disputes, and leading to a “significant” postponement in the receipt of payment.

“While this only affects a small part of Radiology Partners’ revenue, the delay in cash collections is weighing on liquidity and reducing the capacity for further operational challenges in the short term,” analyst Richa Deval and colleagues wrote March 31. “[US Radiology Specialists], on the other hand, has no exposure to the No Surprise billing act.”

In response to the growing backlog, CMS upped the administrative fee for the IDR process from $50 to $350 in December. Deval and colleagues said they expect this change will result in a “modest reduction” in claims submitted to IDR entities, but it may continue to constrain radiology providers’ margins.

“We expect this should improve the pace of collections and liquidity and bring payers and providers to the negotiating table for in-network contracts,” the analysis noted.

S&P also highlighted physicians’ February court victory tied to the No Surprises Act (a Texas judge agreed that the NSA overemphasized the importance of the “qualifying payment amount”) and subsequent resumption of the paused IDR process in March. Experts view the ruling as “positive” for radiology providers’ payment prospects, though the pause may have further hindered cash collections.

The American College of Radiology shared an April 21 update on the ongoing litigation, emphasizing the $350 admin fee as one point of dispute.

“Notably, the court appeared sympathetic to physicians’ contentions that the government failed to give physicians a meaningful opportunity to comment on the significant 600% IDR fee increase over 2022 fees,” ACR reported, adding that it expects the court to rule on the fee hike “by early June, if not sooner.”