Independent Dispute Resolution Outcomes for Planned Procedures under the No Surprises Act
Providers won nearly 90% of disputes for planned surgical and endoscopic procedures that went through the Independent Dispute Resolution (IDR) process, with provider payments (awards) far exceeding benchmarks that reflect in-network commercial rates and Medicare rates.
The No Surprises Act (NSA) protects patients from unexpected medical bills and established a process to resolve payment disputes between plans and providers for certain out-of-network services. This study analyzed awards for 7,304 disputed claim lines involving planned procedures, including spine surgery, plastic surgery, and endoscopic services that went through the IDR process.
This study, published in Health Affairs Scholar, found IDR awards were extreme, averaging more than 50 times benchmarks reflecting in-network commercial rates. Provider win rates did not change with increasing provider or insurer offers. Policy changes are needed so that the NSA does not contribute to rising healthcare costs, particularly for planned out-of-network care that should not be a “surprise” for patients.
Related Public Policy Research
The No Surprises Act: Dismissal Rates for Out-of-Scope and Ineligible Disputes
A majority of disputes submitted under the No Surprises Act are outside the scope of the law or procedurally ineligible for independent dispute resolution (IDR). By law, these disputes should be dismissed, but 64% of them still result in payment determination.
The No Surprises Act: Independent Dispute Resolution for Planned Procedures
This study found that provider payments from the No Surprises Act’s Independent Dispute Resolution (IDR) process for certain planned out-of-network procedures far exceeded in-network commercial and Medicare benchmarks. Policy changes are needed to align IDR outcomes with the law’s original intent and prevent excess costs.
Arbitration Outcomes for Out-of-Network Medical Bills Under the No Surprises Act
This study, published in INQUIRY: The Journal of Health Care Organization, Provision, and Financing, compared final payments for out-of-network care from disputes that underwent arbitration under the No Surprises Act in 2023 to commercial in-network rates and Medicare rates.