The American Medical Association (AMA) and nearly 100 other organizations are backing legislation that aims to force payers to comply with independent dispute resolution (IDR) payment determination rules. This unified action comes amid ongoing reports from providers about nonpayment, delayed payment, and improper billing practices by payers. Healthcare providers are now asking lawmakers to put more pressure on payers to comply with the No Surprises Act.
A Letter to Congress: Detailing the Problem
In a letter to congressional leaders, the AMA, 50 state medical societies, and 45 healthcare groups outlined continued noncompliance by payers. According to the organizations, payers are not abiding by the payment requirements set by law when providers are successful in the IDR process. The letter specifies that payers continue to inappropriately bill patients, delay payments past the 30-day timeframe required by law, and, in some cases, refuse to pay providers completely. As a result, physician practices are forced to absorb unpaid costs and deal with payment delays while waiting for the funds they are legally entitled to receive.
The Need for Stricter Enforcement
The letter from these healthcare organizations calls for stricter enforcement of IDR rules, emphasizing that stronger measures are necessary to bolster the implementation of the No Surprises Act. The organizations state that without adequate enforcement, the law’s ability to protect providers and patients is compromised, as payers continue to ignore payment determinations and skirt their legal responsibilities.
Legislative Response: The No Surprises Act Enforcement Act
To address these ongoing issues, the organizations are supporting a bipartisan, bicameral bill known as the No Surprises Act Enforcement Act (H.R. 4710/S. 2420). If enacted, this legislation would require payers to comply with IDR payment requirements and impose penalties if they fail to pay providers within 30 days. The bill also proposes interest charges on any unpaid amounts when payers do not pay on time. The organizations explained in their letter that such legislation is necessary to bridge the “enforcement gap” that has made IDR process improvement efforts ineffective, as payers continue to ignore payment determinations. They believe this legislation would “restore balance achieved by the statute and ensure accountability.”
Calls for Greater Transparency and Guidance
The organizations are also advocating for greater transparency and enhanced guidance to improve the IDR process. For example, they support proposals that would require payers to identify claim eligibility in the initial remittance advice provided to providers. This step is aimed at addressing payer claims of a flood of ineligible claims entering the IDR system.
Litigation and Disputes in the IDR Process
Payers have even taken the step of suing hospitals and other provider groups, alleging that some providers are gaming the IDR process by submitting an excessive number of claims in an effort to win payment determinations. Despite these lawsuits, providers win the vast majority of IDR cases, with rates exceeding 80%, according to Georgetown University’s Center of Health Insurance Reforms. Providers also win much higher payments than payers would typically reimburse for care. Data shows that the prevailing provider offer was 383% of the qualifying payment amount, which generally represents the median contracted rate for a payer.
Ongoing Challenges with Claim Eligibility
However, the AMA and other provider organizations pointed out in an April 27 letter to leading government officials that determining claim eligibility under the IDR process remains a significant challenge. Payers, they noted, frequently fail to convey when claims are eligible, even though they possess that information. In many cases, payers also do not participate in open negotiations as required.
Formalizing Open Negotiations Process
In their latest letter, the AMA and other organizations called for formalizing the open negotiations process, which currently takes place before payers and providers enter the IDR process. They argue that formalizing this stage could lead to better outcomes and fewer disputes escalating to IDR.
AMA’s Continued Advocacy
Nevertheless, the AMA remains one of the most powerful lobbying forces in the healthcare industry, touting an “aggressive legislative advocacy effort.” The group, along with medical societies and healthcare organizations, remains committed to passing the bill to ensure the successful implementation of the No Surprises Act, including what they describe as “achieving the balanced framework Congress intended,” as stated in their letter.
A Commitment to Protecting Patients and Providers
The organizations concluded their letter with a clear message:
“Our organizations remain fully committed to the core purpose of the No Surprises Act: protecting patients from surprise medical bills while ensuring physicians and other healthcare providers receive fair and timely payment for the medical services they provide.”
Summary: The Path Forward
The ongoing difficulties faced by providers in securing timely, fair payment from payers highlight the need for strong enforcement of the No Surprises Act. With the continued advocacy of the AMA and nearly 100 other organizations, there is sustained pressure on Congress to address these issues, pass meaningful enforcement legislation, and ensure the law functions as intended. Until then, providers and patients alike remain affected by payment delays, noncompliance, and uncertainty in the IDR process, underlining the urgent need for legislative action and improved payer accountability.