Providers win about 80% of “No Surprises Act” cases that reach arbitration, according to Elevance Health Public Policy Institute research published Dec. 10 in Inquiry: The Journal of Health Care Organization, Provision and Financing.
Researchers reviewed Elevance Health’s 2023 dispute data. While the team compared final payments to the qualifying payment amount — the median in-network market contracted rate — and Medicare rates, they also looked at claims-weighted in-network rates. Arbitration payments exceeded these benchmarks.
While the Congressional Budget Office expected savings that would steer out-of-network rates toward in-network rates, the study shows otherwise. For the same services, median final arbitration totals were 3.72 times the QPA, 2.04 times real-world median local in-network commercial rates and 4.5 times Medicare rates.
Six providers, seeming to be emergency physician groups or staffing companies, accounted for more than half of the disputes.
“It seems to be that some providers are finding this to be a lucrative business model. The arbitration system was really not supposed to be someone’s new business model. This is supposed to be for specific cases where there’s a disagreement,” Aliza Gordon, director of research at the Elevance Health Public Policy Institute, told Becker’s. “If it becomes an easy process, and you’re winning a lot of money, it is working for those providers.”
Going forward, policymakers should look to close loopholes for elective services and ground arbitration in the QPA or another metric, Ms. Gordon said.
Other recent research identified at least $5 billion in costs due to the independent dispute resolution process and gaps in disputes eligible for arbitration.
