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- CAP Proactively Working to Strengthen Enforcement of Payment Decisions Under No Surprises Act
The CAP is aware of some insurers delaying payment or refusing to honor decisions rendered after pathologists win a decision following the federal independent dispute resolution process.
In April, the CAP wrote a letter to the Center for Medicare and Medicaid Services (CMS) urging the agency to strengthen enforcement of the No Surprises Act dispute resolution requirements – including implementing financial penalties in the case of nonpayment – and to improve the process of submitting a formal complaint against a private insurer.
The No Surprises Act requires that insurers and providers undergo an independent arbitration process to settle their differences without involving patients. As highlighted in an August 3 story featured in Axios titled “Doctors say insurers are ignoring orders to pay surprise billing disputes,” instances of insurance nonpayment regarding surprise billing continue to affect physicians in all specialties.
A survey by Americans for Fair Health Care of more than 48,000 physicians in 45 states across 12 specialties found:
- 52% of all arbitration-determined payment amounts were not paid at all.
- On average, it has taken 236 days (approximately 8 months) for a payment dispute to be resolved and paid.
- Only 24% of Independent Dispute Resolution (IDR) submissions are completed – an average of 67% remain pending.
- And many payers are not engaging in mandatory open negotiations.
The Texas Medical Association recently sued CMS over several aspects of the No Surprises Act. CMS suspended the IDR process after a federal court judge ruled in favor of the Texas Medical Association last week. The judge found that the CMS did not follow processes to increase fees. The CAP also objected to the fee increase in the past.
The CAP continues to work with the CMS to address problems members and others are experiencing.