The No Surprises Act, implemented in 2022, was designed to shield patients from unexpected medical bills and set up an independent dispute resolution process for payers and physician groups to settle out-of-network payments.
But the law has become a flashpoint among physician groups and payers alike in recent months, as some leaders say the IDR process has created legal loopholes, financial burdens and delays in care.
In response, HHS, CMS, and the departments of Labor and Treasury finalized a rule May 28 that overhauled several aspects of the NSA, including the IDR process. Under the new policies, the administrative fee per party per dispute will drop from $115 to $15, a reduction of more than 85%. The change directly affects the economics of disputing smaller claims, an issue that has frustrated specialty practices since the IDR process was first launched.
Separately, if either party fails to pay its administrative or certified IDR entity fee by the time its offer is due, that offer will not be considered received, though the financial obligation remains. The rule includes several other administrative adjustments aimed at increasing accountability and efficiency in the process.
Jody Crane, MD, chief medical officer of Knoxville, Tenn.-based TeamHealth, recently joined Becker’s to share insights as to how his system navigates the IDR process and why he’s hopeful about new reforms.
Editor’s note: Responses have been lightly edited for clarity and length.
Question: How has the No Surprises Act changed the way your practice approaches contract negotiations with insurers — and has it shifted the power dynamic at all?
Dr. Jody Crane: TeamHealth has had a longstanding policy against balance billing patients for out-of-network care, and our preference has always been to remain in-network with health insurers whenever fair reimbursement terms can be reached. The No Surprises Act did not change that approach, but it did create an independent pathway for resolving payment disputes when negotiations fail or when insurers underpay for care. The No Surprises Act serves as a last resort when insurers are unwilling to negotiate reasonable agreements or fail to appropriately reimburse out-of-network care.
Q: Have you or your group ever gone through the IDR process? What was your experience, and would these rule changes have made a difference?
Dr. Crane: TeamHealth utilizes the IDR process in good faith when it is the only way to recoup underpayments from insurers. In more than 90% of these cases, independent arbiters found that insurers underpaid for the care of a TeamHealth patient. While the No Surprises Act has successfully protected patients from surprise bills, administrative hurdles can make dispute resolution more difficult than necessary. We believe that the recent reforms will make the IDR process more accessible and transparent, including lowering administrative fees, allowing clinicians to batch similar claims together, and requiring insurers to provide clearer information about which claims are eligible for arbitration.
Q: What’s one thing you wish policymakers understood about how billing disputes actually play out on the ground in your practice?
Dr. Crane: Policymakers should understand how small the universe of IDR claims is relative to the total number of medical claims. Approximately 93% of out-of-network claims are resolved without entering IDR according to an AHIP/Blue Cross Blue Shield Association survey. The disputes that reach arbitration are typically the most complex cases, not representative of routine claims resolution. IDR is the exception, not the rule. Policymakers should also understand that providers often lack visibility into how insurers calculate the qualifying payment amount, making it difficult to meaningfully evaluate payment determinations.
Q: The new rule requires good-faith negotiations before disputes enter arbitration — do you think insurers will actually comply, and what should happen when they don’t?
Dr. Crane: We hope insurers engage in meaningful good-faith negotiations, as Congress intended. Most payment disputes should be resolved through direct negotiation whenever possible. However, when negotiations break down or parties cannot reach agreement, the IDR process provides an important independent backstop to ensure disputes can be resolved fairly while keeping patients out of the middle.