If you’re in an accident or having a heart attack, you need the quickest care available. You probably don’t have time to check whether the nearest hospital takes your insurance. And once you’ve recovered, the last thing you need is a surprise medical bill for out-of-network care.
Luckily, Congress prohibited these bills through the “No Surprises Act”—which protects privately insured patients from having to pay the difference between what their insurance covers and the amount an out-of-network health care provider bills them for care. But someone still needs to cover these costs. So far, a government forum designed to resolve billing issues between insurance companies and health care providers has received hundreds of thousands more disputes than expected—and most remain unresolved.
Today’s WatchBlog post looks at our new report on the challenging roll out of the No Surprises Act.
A large volume of unresolved disputes
The No Surprises Act prohibits health care providers (such as emergency department physicians and air ambulances) from “balance billing” —pushing uncovered charges onto the patient and surprising them with big medical bills. Now health care providers and insurance companies that can’t come to an agreement on their own must decide how much should be paid for out-of-network care through a new federal government forum.
The government expected to receive about 22,000 payment rate disputes through the forum in 2022—but ended up receiving nearly 490,000 through June 2023. Most disputes were over emergency care.
While the forum was meant to help health care providers and insurance companies determine payment rates for out-of-network care, nearly 61% of these disputes remained unresolved as of June.
Number of Disputes and Unresolved Disputes by Calendar Quarter
A big reason for why so many disputes remain unresolved is the difficulty of determining which disputes are eligible for the federal government forum, as some should go through a state process instead.
In addition, both health care providers and insurance companies told us the forum can be burdensome to use, particularly the online portal used to process disputes. Providers also described other concerns they have with the roll-out of the forum. For example, we heard about backlogs in determining payment rates, which could put health care providers in a pinch for cash. Insurance companies also said they were being overwhelmed by the sheer volume of disputes.
What is the federal government doing to address these challenges?
Federal agencies overseeing the new dispute resolution process, including the Centers for Medicare & Medicaid Services and the Department of Labor, are coordinating their work and implementing improvements. These agencies also respond to and investigate complaints. But the agencies told us their ability to increase enforcement of the rules is limited because of budget constraints.
The agencies have also proposed new rules that are expected to ease the challenges identified by improving communication between health care providers and insurance companies in an effort to get more timely agreements. For example, under the new rules, the agencies will require these players to submit more information up front to help determine dispute eligibility, and the agencies may step in during periods of systemic delay.
Learn more about this issue by checking out our new report.
- GAO’s fact-based, nonpartisan information helps Congress and federal agencies improve government. The WatchBlog lets us contextualize GAO’s work a little more for the public. Check out more of our posts at GAO.gov/blog.