FOR IMMEDIATE RELEASE

July 17, 2024

+1 (202) 823-2333

media@action4health.org

WASHINGTON — Last week, the Centers for Medicare & Medicaid Services (CMS) released its first audit of the No Surprises Act (NSA). This audit has confirmed what we—and many other stakeholders—have been saying for a long time: health insurance companies are manipulating this landmark law at virtually every step.

With its probe of Aetna and the NSA's qualifying payment amount (QPA), CMS found that, among other infractions:

• "The Issuer’s QPA calculation methodology incorrectly used claim payment amounts instead of contracted rates and counted each claim as its own contracted rate, even when the claims were for the same item or service..."

• "The Issuer failed to provide either a statement itself or compliant statement that, generally, the provider or facility may initiate the IDR process within four days after the end of open negotiation period."

• "The Issuer failed to share the QPA with an initial payment or notice of denial of payment."

With these new revelations, Action for Health is renewing its calls on CMS and Congressional leaders to immediately fix other parts of the NSA's independent dispute resolution (IDR) process that also remain badly broken.

IDRE Selection. We have learned that, if the initiating party in an IDR claim does not respond to CMS' e-mail within hours—even after business hours—then health insurance companies receive their choice of IDR entity (IDRE) to adjudicate the dispute, which they then can use to unfairly win the IDR process.

See here, here, and here for examples that we have uncovered. This is prejudicial and extremely troublesome.

False Ineligibility Claims. Health insurance companies continue to falsely claim to IDREs that certain IDR cases brought to them are ineligible. Insurance companies then provide false reasons why, e.g., a.) the state in which the IDR dispute is made will process the case; b.) the initiating party was in-network; or c.) the NSA's IDR process does not apply to the company's specific coverage plan.

These are overwhelmingly fraudulent claims, and they are slowing the entire IDR decision making process to a crawl.

Failure to Meet Payment Deadlines. When health insurance companies lose an IDR claim, they are refusing to pay the binding amount awarded by the IDRE within 30 days.

This is in direct violation of the NSA and must be corrected immediately through rigorous enforcement and oversight.

Action for Health President Christopher Sheeron stated:

"CMS' first audit of the NSA is a longed-for wake-up call. Physicians, hospitals, and facilities across the country continue to face significant difficulties with the federal IDR process. As we'll continue to highlight, health insurance companies are routinely slowing down the process to an extent that it is largely unworkable. Both the Biden administration and Members of Congress consistently talk about the threats not only of healthcare consolidation, but also to patients' access to care. It's time for leaders in Washington to recognize that fixing the NSA's IDR process now is a solution to both problems."

Action for Health is a national non-profit advocacy organization working to ensure fair outcomes for critical healthcare issues. The organization educates policymakers, the media, and concerned citizens about policies, laws, and regulations that are important to patients.

Action for Health | +1 (202) 823-2333 | media@action4health.org | action4health.org