HHS released its third annual report Feb. 9 that evaluates how the No Surprises Act has affected healthcare markets.
The report was produced with analytical support from RAND, and extends claims data trends through 2022, the first full year after the law took effect.
Self-insured employer plans, which were largely exempt from state surprise billing laws prior to the NSA, experienced steeper declines in out-of-network payments than fully insured plans between 2019 and 2022, according to the report. Average out-of-network per-claim payments for emergency services in self-insured plans fell 41% during the period, compared to 22% for fully insured plans.
Seven notes:
1. The prevalence of out-of-network bills fell 15% for emergency services and 11% for non-emergency services at in-network facilities between 2021 and 2022. Compared to the 2019 pre-pandemic baseline, declines were 24% and 17%, respectively. Out-of-network billing had been trending downward for years, but the rate of decline accelerated notably after implementation, according to the report.
2. Average out-of-pocket payments for out-of-network emergency services dropped 54% between 2019 and 2022, from $94 to $43. For non-emergency services at in-network facilities, the decline was 32%. Both categories saw their steepest single-year drops between 2021 and 2022.
3. Self-insured plans experienced larger declines in both out-of-network billing prevalence and average payments than fully insured plans. Average total per-claim out-of-network payments for emergency services in self-insured plans fell 31% in a single year.
4. TeamHealth, SCP Health, Envision and Radiology Partners collectively filed over two-thirds of the roughly 197,000 IDR disputes over emergency and non-emergency services closed in 2023. Emergency medicine providers alone accounted for 60% of disputes, followed by radiology at 15%.
5. Providers won about 80% of IDR disputes for emergency and non-emergency services and roughly 85% for air ambulance services. Median payment determinations were at least double the median qualifying payment amounts and ranged from 172% to 349% of median commercial out-of-network payment rates. For the most common emergency department code, the median payment determination was $529 versus a median QPA of $229.
6. The federal government originally projected 17,000 IDR disputes per year. The 2023 data contained more than 209,000 unique disputes, roughly 12 times the estimate. The average dispute took 91 business days to resolve.
7. Hospital markets continue to concentrate steadily, with only 17% of hospital referral regions falling below the “highly concentrated” threshold in 2022, down from 33% in 2008. Physician practice acquisitions have held relatively stable, and deals targeting surprise billing-adjacent specialties like emergency medicine and radiology have declined to just 2% of physician M&A volume in 2023, down from about 35% a decade earlier. The report said that that providers facing revenue pressure from the NSA could pursue consolidation to strengthen their negotiating position, but noted that it is too early to attribute any market structure changes to the law.
