EDPMA Study: No Surprises Act Independent Dispute Resolution Process

News provided by

Emergency Department Practice Management Association (EDPMA)

Mar 09, 2023, 13:00 ET

EDPMA study reveals 91% of claims filed through the independent dispute resolution process remain open and unadjudicated due to the flawed implementation of the No Surprises Act. Almost 96% of outstanding claims are 5+ months old

MCLEAN, Va., March 9, 2023 /PRNewswire-PRWeb/ -- The No Surprises Act (NSA) was designed to keep patients out of the middle of payment disputes and to ensure fair and balanced resolutions of payment disputes between healthcare providers and payors. A study released by the Emergency Department Practice Management Association (EDPMA) reveals that the Independent Dispute Resolution (IDR) process as outlined in the No Surprises Act is broken, causes harm to U.S. emergency departments and risks patients' access to quality emergency care.

With the NSA being in place for one year, EDPMA commissioned a study of its members to understand the real-world impact of the federal law. While it appears the NSA achieved its goal to protect patients, the flawed implementation of the legislation threatens how emergency departments are staffed and could jeopardize the emergency department safety net.

The commissioned study analyzed almost 220,000+ outstanding claims and revealed:

  • 91% of filed claims remain open and unadjudicated. Payers ignoring claims in the open negotiation period contribute to the significant volume of IDR claims.
  • 95.6% of outstanding claims are 5+ months old from 127 health plans.
  • Payers are not participating in the 30-day open negotiation period and the IDR process as expected by statute. 68% of filed IDR claims did not receive replies from health plans during the 30-day open negotiation period. Respondents further reported that 52% of payers did not acknowledge an IDR claim had been filed, and that 75% of payers who actually responded in the IDR process made NO actionable offers.
  • Rapid and effective enforcement is not happening. Emergency medicine physician groups are filing complaints with the Centers for Medicare and Medicaid Services (CMS) and the Center for Consumer Information and Insurance Oversight (CCIIO), as well as issuing demand letters to health plans. Respondents reported that CMS responded to 14% of their complaints.
  • 87% of payers did not pay in accordance with the IDR Entity decision. Of respondents,1/3 reported 100% noncompliance by health plans, 1/3 reported noncompliance from 89% to 98% of the time, and 1/3 reported noncompliance 37% of the time.

EPDMA is committed to a viable and sustainable No Surprises Act implementation. We continue to offer solutions, input, and data to the Department of Health and Human Services, the Department of Labor, and the Department of Treasury to:

Implement the law as designed

  • Encourage continued Congressional involvement
  • Ensure all parties fully participate in the IDR process
  • Sustain patient protections under EMTALA

See the study summary here.

"We strongly believe that emergency physicians should be fairly reimbursed for the delivery of emergency care, and payers should do their part to not undermine the emergency medical health care delivery system and the overall health of our healthcare system. EDPMA will continue to advocate for its members and patients," says Don Powell, DO, FACEP, EDPMA Chair of the Board.

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About EDPMA
The Emergency Department Practice Management Association (EDPMA) is the nation's only professional physician trade association focused on the delivery of high-quality, cost-effective care in the emergency department. EDPMA's membership includes emergency medicine physician groups of all sizes, as well as billing, coding, and other professional support organizations that assist healthcare providers in our nation's emergency departments. Together, EDPMA's members deliver (or directly support) health care for about half of the 146 million patients that visit U.S. emergency departments each year. Visit http://www.edpma.org.

Media Contact

Cathey Wise, Executive Director, Emergency Department Practice Management Association (EDPMA), 703.506.3282, [email protected]

SOURCE Emergency Department Practice Management Association (EDPMA)