As
a
member
of
the
Coalition
Against
Surprise
Medical
Billing,
Katy
Spangler
helped
push
for
the
No
Surprises
Act
in
2020.
However,
on
Wednesday,
she
took
the
stage
at
the
AHIP
Medicare,
Medicaid,
Duals
&
Commercial
Markets
Forum
to
call
for
changes
to
the
law.
The
No
Surprises
Act
protects
patients
from
unexpected
bills
and
removes
them
from
insurer-provider
payment
friction.
The
act
requires
insurers
and
providers
to
enter
into
30
days
of
open
negotiation
to
determine
how
much
providers
are
paid.
If
they
can’t
come
to
an
agreement,
either
side
can
use
the
Independent
Dispute
Resolution
(IDR)
process,
in
which
a
provider
submits
a
payment
offer
and
an
insurer
submits
a
payment
offer
and
then
a
neutral
arbitrator
(called
an
IDR
entity)
picks
one.
While
the
act
is
successful
in
protecting
patients
against
surprise
bills,
Spangler
and
others
in
the
industry
are
arguing
that
the
IDR
process
is
now
being
abused
by
some
providers.
What
was
meant
to
be
a
last
resort
has
instead
seen
an
explosion
in
volume,
with
providers
initiating
the
vast
majority
of
IDR
cases
and
winning
most
of
the
time
at
significantly
inflated
award
levels,
she
said.
“When
we
have
an
in-network
surgeon
who
has
agreed
to
$800
for
the
reimbursement
for
that
surgery,
but
an
assistant
surgeon
takes
that
same
case
to
IDR,
and
they
get
$80,000,
that
is
unsustainable.
…
This
is
crazy
—
we
have
got
to
fix
this
problem,”
Spangler
said
on
the
panel.
Recently
published
data
from
another
panelist
backs
this
up.
Kennah
Watts,
a
research
fellow
at
the
Center
on
Health
Insurance
Reforms
(CHIR)
at
Georgetown
University’s
McCourt
School
of
Public
Policy,
explained
on
the
panel
that
there
have
been
3.4
million
IDR
disputes
from
2022
through
June
2025.
CMS,
however,
anticipated
there
to
be
about
55,000
over
that
same
time
period.
Watts
added
that
providers
and
healthcare
facilities
are
initiating
99%
of
disputes.
“We
also
see
that
not
only
are
providers
submitting
the
vast
majority
of
disputes,
but
they’re
winning
a
majority
as
well,
and
they’re
winning
at
much
higher
rates
than
plans.
…
We
can
see
that
to
date,
[when
providers]
win,
they
have
a
median
win
rate
that’s
about
4.5
times
the
in-network
rate,”
she
said.
And
the
IDR
process
is
costly:
from
2022
to
2024,
the
IDR
process
has
incurred
about
$5
billion
in
total
costs,
according
to
Watts’
data.
A
health
insurance
executive
on
the
panel
—
Josh
Goldberg,
executive
director
of
health
policy
at
Health
Care
Service
Corporation
—
echoed
these
issues.
He
noted
that
the
company
has
seen
about
750,000
IDR
disputes
and
keeping
up
has
been
extremely
challenging.
“Between
two
months,
you
might
see
a
swing
of
40%
in
terms
of
volume
and
so
accurately
staffing
for
that
fluctuating
volume
is
very
difficult,”
he
said.
“We
see,
I
think,
what
may
be
intentional
manipulation
of
the
volume
to
try
and
concentrate
a
lot
of
volume
in
a
short
period
of
time
to
make
the
response
more
difficult.
…
Currently,
we
have
well
over
400
people
just
working
IDR
disputes.
That’s
significant.
Those
salaries,
the
cost
of
that
all
has
to
be
paid
somewhere,
and
it
comes
out
in
premiums.”
He
added
that
because
of
the
volume
of
IDR
disputes,
he
doesn’t
think
IDR
entities
are
able
to
give
the
disputes
adequate
consideration.
He
noted
that
a
$7,000
claim
for
a
respiratory
panel
resulted
in
a
$255
million
award
through
the
IDR
process.
“Now,
to
their
credit,
we
went
back
to
the
IDR
institute
and
said,
‘You
want
to
look
and
see
if
there’s
a
mistake
here,
because
this
can’t
be
right.’
They
acknowledged
that
they
had
an
error,
selected
the
wrong
prevailing
party,
and
they
went
to
CMS
and
had
that
reopened,”
Goldberg
said.
“But
I
think
it’s
indicative
of
the
stress
that
they
are
under
to
close
cases
very
quickly,
and
that
results,
I
think,
in
a
reduction
in
the
quality
of
work
that
they’re
able
to
do.”
As
for
how
to
improve
the
IDR
process,
Spangler
argued
that
the
current
administration
should
take
regulatory
action
to
block
ineligible
claims
from
entering
arbitration
and
address
flawed
incentives
that
encourage
improper
IDR
rulings.
However,
congressional
action
may
be
needed
as
well.
“There’s
a
lot
that
we
think
can
happen
to
make
this
less
bad,
but
it’s
really
bad,
and
I’m
so
sad
to
say
it,”
Spangler
said.
Photo:
KLH49,
Getty
Images