CMS received nearly 15K NSA complaints, mostly against providers

Data hints at No Surprises Act compliance issues

Complying with the No Surprises Act continues to be a challenge for healthcare providers, the report suggested.

Most complaints against providers involved surprise billing for either non-emergency services at an in-network facility or emergency services. The No Surprises Act specifically prohibits providers from billing patients for unexpected out-of-network care, particularly in emergency situations.

The law also bans out-of-network ancillary facility providers, such as anesthesiologists, radiologists and pathologists, from charging patients beyond in-network cost-sharing amounts if they are treated at an in-network facility.

However, CMS tallied 4,806 complaints against providers alleging surprise billing for non-emergency services at an in-network facility and another 2,363 complaints alleging surprise billing for emergency services.

CMS also reported 1,646 complaints against providers related to the good faith estimate requirement, which requires providers to give uninsured and self-pay patients a cost estimate within a certain number of days, depending on when the appointment was scheduled.

Providers have acknowledged issues with identifying services eligible for the federal IDR process. They say payers have that information but refuse or neglect to provide it when issuing payment or denial notices. Regardless, payers have reported a large number of ineligible claims entering the IDR process, leading to backlogs and improper awards.

Top NSA complaints against payers

The most common complaints made against issuers and non-federal governmental plans bound by the No Surprises Act during the report's period included:

• Noncompliance with the qualifying payment amount requirements (844 complaints).
• Late payment after 30 days from the IDR determination (664).
• Noncompliance with requirements to send the initial payment or notice of denial within 30 days (253).

Providers have also decried payer behaviors, including noncompliance with IDR process timelines. For example, the American Medical Association wrote to federal officials in April describing payer abuses and accusing many health plans of circumventing the law's requirements to withhold payments from providers.

Payer calculations of the qualifying payment amount, which is used in the federal IDR process to determine payment awards, have also stirred controversy. Providers have argued that payers have artificially deflated the amounts to pay them less.

Upcoming changes to the federal IDR process could address some of the complaints in the latest CMS report.

The federal agency finalized a rule late last month that will overhaul batching requirements, payer-provider communications and the open negotiation period. The rule seeks to address problems with IDR eligibility and inefficiencies, such as a large dispute backlog.

CMS said the changes will take effect by early September.

Jacqueline LaPointe is an Executive Editor at Xtelligent Healthcare Media, covering revenue cycle management, healthcare payers, health policy and health IT since 2016.