Work

No Surprises Act independent dispute resolution outcomes for emergency services

Year: 2024

Type: article

Abstract: The No Surprises Act banned surprise billing and established a final-offer arbitration system, independent dispute resolution (IDR), to resolve disagreements between health plans and providers. One factor that arbiters must consider in the IDR process is the qualifying payment amount (QPA), the median contracted rate for the same or similar service in the same market as computed by health plans. We analyzed public IDR data from 2023 for the most common disputed professional service: evaluation and management of a moderate to severe emergency medicine visit. Providers won 86% of cases, with mean decisions 2.7 times the QPA. Private equity-backed providers won more often and higher monetary awards than other providers. The mean QPA was 2.4 times Medicare payments. Disputes were dominated by a small group of health plans and providers, so payments may not reflect the overall market for emergency services.

Source: Health Affairs Scholar

DOI: 10.1093/haschl/qxae132

Authors: Erin L Duffy, Christopher Garmon, Loren Adler, Adam Biener, Erin Trish

Institutions: University of Southern California, University of Missouri–Kansas City, Brookings Institution, Lafayette College

Language: English

Topic: Healthcare Policy and Management

Subfield: Economics and Econometrics

Field: Economics, Econometrics and Finance

Domain: Social Sciences

SDG: Peace, justice, and strong institutions

Open Access status: gold

Estimated APC paid: $3,308