CMS Receives 12K No Surprises Act Complaints; Secures $1.7M in Restitution

The most common complaints against health plans included problems in determining eligible payment levels, and the most common complaints against providers concerned surprise billing.

Key Highlights:

• Federal regulators have fielded over 12,000 complaints of noncompliance with the No Surprises Act by June 2023, per new CMS data.
• The most frequent complaints against providers involve surprise billing, while insurers are often accused of miscalculating qualifying payment amounts (QPAs).
• CMS has recovered over $1.7 million in restitution for consumers and providers, addressing grievances under the No Surprises Act.

In-Depth Analysis:

1. The Centers for Medicare & Medicaid Services (CMS) revealed that it has received more than 12,000 complaints regarding noncompliance with the No Surprises Act as of June 2023. This law, enacted in early 2022, aims to eliminate unexpected medical bills by holding patients harmless when they receive out-of-network care at an in-network facility or other similar situations. The CMS has successfully secured over $1.7 million in restitution for consumers and providers from these complaints, signaling its commitment to enforcing this vital consumer protection law.
2. The most common complaints against healthcare providers involve surprise medical billing, both for emergency and non-emergency services, a practice strictly prohibited by the No Surprises Act. On the other hand, health plans have been frequently criticized for incorrectly calculating QPAs, which are essential in determining fair reimbursement rates for out-of-network care.
3. The No Surprises Act also established an independent dispute resolution (IDR) process for resolving payment disagreements between insurers and providers. Both parties submit their payment offers, and a third-party arbiter selects the more appropriate amount. However, this process has sparked contention, leading to numerous lawsuits from providers who feel the system is skewed in favor of insurers. Complaints have also arisen about insurers delaying or neglecting payments awarded through arbitration, further complicating compliance.
4. In the second quarter of 2023 alone, CMS received an additional 1,500 complaints related to the No Surprises Act, adding to the 10,500 received by March. The vast majority of these complaints target providers, particularly for issuing surprise bills and failing to provide good faith estimates required before delivering out-of-network care.
5. Regarding health plans, most complaints center around QPA miscalculations. QPAs represent the median amount insurers typically pay for a given service within a specific geographic area, playing a crucial role in determining out-of-network reimbursement. Providers have accused insurers of deliberately setting QPAs too low to minimize payments.
6. In response to these issues, CMS conducted its first audit of an insurer’s compliance with the No Surprises Act, focusing on CVS Aetna in Texas. The audit uncovered both overestimations and underestimations in QPA calculations, lending credibility to providers’ concerns.
7. Late payments following IDR determinations represent another significant grievance against insurers. The frequent pauses and restarts of the IDR process due to ongoing litigation have exacerbated the backlog of claims, putting additional strain on the system. The federal government has received 13 times more surprise billing disputes in the first half of 2023 than anticipated for the entire year, underscoring the scale of the challenge.
8. Despite these difficulties, the No Surprises Act has significantly benefited patients. According to health insurance groups, more than 10 million surprise medical bills were prevented in the first nine months of 2023, highlighting the law’s positive impact on protecting consumers.