VIDEO: Insurance companies have weaponized the law with no surprises, which could impact patient care

VIDEO: Insurance companies have weaponized the law with no surprises, which could impact patient care

Ed Gaines, JD, CCP, Vice President of Regulatory Affairs and Industry Liaison, Zotec Partners, discusses the impact of the No Surprises Act on healthcare and medical imaging at the 2022 meeting from the Radiological Society of North America (RSNA). Gaines works with the RSNA on billing and health insurance issues and has spoken in sessions at the 2022 RSNA meeting.

The No Surprises Act (NSA) was created to protect patients from high costs, surprise medical bills, and shield consumers from payment disputes between a healthcare provider or facility and their health insurance plan. But while the law seems like a straightforward policy for most people not involved in healthcare, costs in the US healthcare system can vary widely depending on a patient’s level of insurance, deductibles, negotiated agreements between insurance companies and specific providers, or whether a patient is covered by Medicare, Medicaid, or pays cash. Prices in the healthcare supply chain also vary by hospital and negotiated agreements with suppliers for everything a hospital or clinic uses, from disposables and drugs to durable equipment and medical devices.

The NSA has been exploited by some insurance companies as a way to keep their own costs low by forcing providers to settle unpaid or underpaid bills using an independent and cumbersome dispute resolution process.

“Insurance companies have weaponized the law unsurprisingly and I don’t think the average person on the street knows that. They think they have coverage for X-ray services, for emergency services or for anesthesia, but I don’t think they have any idea that their insurance plans have taken this law and used it as a battering ram for the provider groups they’ve contracted with for years to say, hey under this new law we don’t have to pay that much anymore I don’t like it you can file with the process where there are 80,000 federally blocked claims and that’s really what is happening right now.

Although he said insurance companies lose these challenges about 80% of the time, it adds a lot of extra work, cost, time and frustration to providers who simply want to be paid for the medical services they provide.

“I think doctors are reaching a point of frustration between burnout and suicide with all the factors hitting them, and I wonder who’s going to take care of us,” Haines explained. “I hear that level of frustration, and I’ve practiced health law for 30 years and I’ve never heard it so loud. So part of my message to patients is that they’re going to have to stand up for doctors, hospitals and that service they expect will be there.”

He explained that the current rate of burnout among physicians due to ongoing compensation issues amid rising costs and declining reimbursements poses a problem for the US healthcare system. He said there is also a growing shortage of doctors and this will eventually prevent people from getting the care they need.

At the same time, he said health insurance costs were rising rapidly and insurance companies were making record profits.

“There’s a lot of money in the system, maybe it’s just mismanaged,” Gaines said. “We spend more per capita than any other country on the planet and yet we don’t have the results.”

Gaines said he told vendors there were still issues with the NSA that needed to be resolved, including legal challenges. He details the first major court case challenging the Texas NSA in the interview. Since then, two more cases have been filed challenging the NSA rules.

Texas’ first legal challenge led the judge to send the rule on how the policy is applied back to federal agencies for further refinement and clarification. This case will be back in court for review in February 2023.

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