AHIP, health systems on opposite sides of No Surprises Act debate

Payers and providers don't agree on much when it comes to the No Surprises Act dispute resolution process. 

In a Sept. 19 hearing held by the House Ways and Means Committee, Jeanette Thornton, executive vice president for policy at AHIP, the trade association representing insurers, said the independent dispute resolution process, or IDR, overwhelmingly favors the "initiating party," — hospitals and air ambulance companies. 

"Between an overwhelming number of disputes and repeated litigation from the Texas Medical Association that has created regulatory uncertainty and repeated starts and stops, the Departments have been hindered in developing an IDR process that works," Ms. Thornton said in her opening statement. "The IDR process should be fair to all parties, with consistent rules, transparency into decisions, and ultimately used rarely." 

As of Sept. 1, all federal dispute resolutions are on pause after a Texas judge ruled in favor of the Texas Medical Association, which argued the dispute resolution process favors insurers. 

In testimony to the committee, Jim Budzinski, CFO of Marietta, Ga.-based Wellstar Health System, said the dispute resolution process disincentivizes payers to keep health systems in their networks, instead relying on dispute resolution to receive higher payments. 

"Wellstar has seen firsthand the actions by large health insurers who refuse to negotiate with us, insist on going out of network and rely on the independent dispute resolution process. We see this as a prime example of how flawed the No Surprises Act implementation has been," Mr. Budzinski said. 

Ms. Thornton said the success of the payer business model "largely depends on having large networks of high-quality, high-value healthcare." 

"The idea that health insurance providers are intentionally withholding required payments to healthcare providers defies our fundamental business model," Ms. Thornton said. "While we advocate for a regulatory structure that incentivizes network participation over IDR, when a provider is owed additional amounts after IDR, because we aim to bring more providers in-network, we have every incentive to view that provider as a potential partner and make timely payments." 

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