Financial Viability of the No Surprises Act Independent Dispute Resolution Process: Radiology and Other Hospital-Based Specialties.

Abstract

Background: The federal No Surprises Act (NSA), designed to eliminate surprise medical billing for out-of-network (OON) care for circumstances beyond patients' control, established the independent dispute resolution (IDR) process to settle clinician-payer payment disputes for OON care. Objective: To assess the fraction of OON claims for which radiologists and other hospital-based specialists can expect to at least break even when challenging payer-determined payments through the NSA IDR process, as a measure of the process's financial viability. Methods: This retrospective study extracted claims from a national commercial database (Optum's de-identified Clinformatics Data Mart Database) for hospital-based specialties occurring on the same day as in-network ED visits or inpatient stays from January 2017 to December 2021. OON claims were identified. OON claims batching was simulated using IDR rules. Maximum potential recovered payments from the IDR process was estimated as the difference between charges and allowed amount. The percentage of claims for which the maximum potential payment, and one-quarter of this amount (a more realistic payment recovery estimate), would exceed IDR fees was determined, using $150 and $450 fee thresholds to approximate the range of final 2024 IDR fees. These values represented the percentage of OON claims that would be financially viable candidates for IDR submission. Results: Among 76,221,264 claims for hospital-based specialties associated with in-network ED visits or inpatient stays, 1,482,973 (1.9%) were OON. Maximum potential payment exceeded fee thresholds of $150 and $450 for 55.0% and 32.1%, respectively, of batched OON claims for radiologists, and 76.8% and 61.3%, respectively, of batched OON claims for all other hospital-based specialties combined. At payment of one-quarter of that amount, these values were 26.9% and 10.6%, respectively, for radiologists, and 56.6% and 38.4%, respectively, for all other hospital-based specialties combined. Conclusions: The IDR process would be financially unviable for a substantial fraction of OON claims for hospital-based specialists (more so for radiology than for other such specialties). Clinical Impact: Although the NSA enacted important patient protections, IDR fees limit clinicians' opportunities to dispute payer-determined payments and potentially undermine their bargaining power in contract negotiations. Therefore, IDR rulemaking may negatively impact patient access to in-network care.