U.S. reports 12,000 complaints over surprise medical billing
MARYLAND, UNITED STATES — The Centers for Medicare & Medicaid Services (CMS) has reported receiving over 12,000 complaints related to noncompliance with the No Surprises Act as of June 2024.
This legislation, enacted in early 2022, aims to shield American consumers from unexpected medical bills due to out-of-network care at in-network facilities or other surprise billing situations.
Restitution and common issues
Federal regulators have secured more than $1.7 million in restitution for consumers and providers from resolved complaints concerning the No Surprises Act.
The most frequent complaints against providers involve surprise billing for both emergent and non-emergent care.
Meanwhile, health plans are primarily criticized for incorrect calculations of qualifying payment amounts (QPAs).
Provider vs. insurer complaints
The majority of complaints under the No Surprises Act have been directed at providers rather than health plans, with an 18-to-3 ratio.
Most provider-related complaints pertain to surprise billing or issues with providing good faith estimates for out-of-network care costs.
Independent dispute resolution challenges
The No Surprises Act established an independent dispute resolution (IDR) process for cases where payers and providers cannot agree on reimbursement amounts. However, this system has faced significant challenges, including pauses and restarts due to lawsuits.
In the first half of 2023, the federal government received 13 times more surprise billing disputes than anticipated for an entire year.
Positive impact on patients
Despite these challenges, the No Surprises Act has benefited patients. An analysis by health insurance groups indicates that more than 10 million surprise bills were prevented in the first nine months of 2023 due to the law’s protections.
How outsourcing can help
Outsourcing presents a viable solution for healthcare providers and insurers dealing with the complexities of the No Surprises Act:
- Compliance management: Specialized offshore firms can assist in tracking regulatory changes, auditing billing practices, and ensuring adherence to the Act’s requirements.
- Medical billing and coding: Offshore specialists can improve accuracy in billing and QPA calculations, addressing key areas of noncompliance.
- Claims processing and dispute resolution: Outsourced teams can efficiently manage the administrative aspects of the IDR process, potentially reducing backlogs.
- Data analysis and reporting: Offshore analysts can identify potential compliance issues and generate required regulatory reports.
- Customer service: Offshore call centers can handle patient inquiries, provide good faith estimates, and explain patient rights under the law.
- Technology implementation: Offshore IT teams can develop software solutions to automate compliance checks and streamline billing processes.
While outsourcing offers potential solutions, healthcare organizations must carefully consider data security, HIPAA compliance, and specific regulatory requirements when implementing any outsourcing strategy.
Overall, the CMS’s ongoing efforts to enforce the No Surprises Act underscore its commitment to protecting consumers from unexpected medical expenses and ensuring compliance across the healthcare industry.
