| |  | The Lead Brief | Armed with fresh data, health insurers are ready to ramp up an advocacy campaign to crack down on what they call abuses of the law meant to protect patients from surprise medical bills. They’ve been pressing for tougher oversight of the independent dispute resolution system — the arbitration process created under the No Surprises Act to settle payment disputes between insurers and providers. Signed into law by President Donald Trump in December 2020, the No Surprises Act stemmed from an influx of patients being hit with massive medical bills after being unknowingly treated by providers outside of their insurance network. Now both sides are arguing the law isn’t working as designed and have pushed regulators to finish implementing the law. → A previously unreported survey from two major insurer groups, AHIP and the Blue Cross Blue Shield Association, claims that independent mediators flagged less than half of the dispute submissions that should have been deemed ineligible, resulting in insurers having to pay out on at least 184,500 improperly filed disputes. The survey obtained data from 25 health plans covering 154 million people nationwide, which represents 71 percent of the commercial insurance market. Plans identified that 39 percent of the more than 1.2 million disputes submitted to the independent dispute resolution process were ineligible, whereas mediators only disqualified 17 percent of the disputes. Why it matters: The survey’s findings add to a concern from insurers that a small group of providers and middlemen are flooding the system with improper filings, driving up administrative costs and premiums — ultimately raising health care costs for patients. An analysis from Georgetown University’s Center on Health Insurance Reforms found the process added between $2 billion and $2.5 billion each year in extra administrative spending, fees and payments above in-network rates. The data show that five provider organizations were responsible for 59 percent of the claims in the last two years. The median payment determination, according to the analysis, has been roughly four times the in-network rate. → It’s also been a legal flash point: There have been more than two dozen No Surprises Act lawsuits, including legal challenges to its implementation, in addition to lawsuits between providers, the middlemen that file disputes for them, and insurance companies. Provider groups argue plans don’t pay their claims in a timely manner, lobbying Congress to impose penalties for those that don’t pay up. WHAT INSURERS WANT Insurance lobbyists have been regularly meeting with federal health officials, the White House and key congressional committees, pushing for what they characterize as more oversight, accountability and transparency. Even with much of Washington frozen by the shutdown, insurers see an opening for the administration to take up what they call a “broken” system. | “When you see the data, you can make a very strong argument that the system is, at best, wasteful and, at worst, being gamed. That’s a recipe for the Trump administration to tackle the problem and implement some solutions.” David Merritt, senior vice president of external affairs at the Blue Cross Blue Shield Association. | | | | Insurers want more federal oversight of the independent dispute resolution mediators, including implementing performance metrics, and the overall process. They’re also asking regulators to tackle the improper filings issue by making providers pay a portion of the fees due to independent dispute resolution entities up front, which could be forfeited if a claim is deemed ineligible. It would also compensate the mediator for their review time — right now, they argue that the entities only get paid when they make a payment determination, which they say creates misaligned incentives to push claims through. Further, all decisions are legally binding, so insurers would like the ability to appeal the outcomes. Katy Spangler, who has been lobbying policymakers and the White House on behalf of the insurer-led Coalition Against Surprise Medical Billing, said the administration could implement simple fixes: Clarifying in guidance, for example, that ineligible claims that make it through the system are not binding. WHAT’S NEXT Some regulations implementing the surprise billing law — including a rule from 2023 that both providers and insurers say would improve the dispute resolution portal — have yet to be carried out. The House Ways and Means Committee, one of the four congressional panels with jurisdiction over the law, recently wrote to regulators and urged them to take action on the pending items. “President Trump’s No Surprises Act was a major victory for American patients in his first term, and the Administration remains committed to building on this and other efforts to expand price transparency in our healthcare system during President Trump’s second term,” Kush Desai, a White House spokesperson, told me in an email. | 
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