Resident Scholar at The American Enterprise Institute for Public Policy Research
- Key implications for payers and providers since the NSA’s (No Surprises Act’s) ratification on 1 January 2022
- Arbitration-offer process for out-of-network claims
- Financial impact on payers, providers and air ambulance players, including levers to offset billing headwinds
- Potential insurance premiums dip and further regulatory developments at the state level
- Increased scrutiny of PE’s longer-term role in healthcare
What recent trends have you been following in the US regulatory space as it relates to surprise billing and the NSA [No Surprises Act] more broadly?
Has there been any notable impact on out-of-network claims volumes since the NSA went into effect on 1 January 2022? Has it shifted consumer or healthcare provider behaviour in any material way?
Could you break down the arbitration process to settle out-of-network claims between a physician group or air ambulance company, for example, and commercial payers?
Does the negotiation leverage in arbitration vary by specialty group or state laws? It appears the payers have the upper hand, but how should we consider negotiation leverage across different arbitration scenarios and subsets of entities?
Do you see a hypothetical breaking point if providers continue to get squeezed on the regulatory side with NSA, reimbursement cuts coming out of CMS [Centers for Medicare and Medicaid Services] and in relationships with commercial payers? Do providers have any bargaining chips given they’re in high demand?
What are your thoughts on the sunsetting of the “greatest-of-three” stipulation? The so-called “greatest-of-three” rule states that the qualifying payment amount is based on at least three median in-network contracts in a specific metropolitan statistical area that currently prescribes a minimum payment for out-of-network emergency services. How might the sunsetting impact the initial out-of-network reimbursement amount, which is used as the starting point in arbitration?
We’re in the early days of implementation, but what are you seeing as far as typical outcomes for these agreements? If an ER [emergency room] or other specialty group was typically billing at several times Medicare, what would be collected post-arbitration? I appreciate this will vary substantially by geography, leverage and other dynamics.
Can other services be added to the NSA via amendments later? Which might be likely candidates?
Are any payers attempting to move out-of-network because of the NSA? Is there substantial upwards pricing pressure when contracts are coming up for renewal to stay in-network?
What levers can providers pull to protect against regulatory headwinds? Is it about trying to increase in-network enrolment or are there other solutions?
What are some longer-term implications for independent providers or small groups who might be unable to afford the revenue collection headwinds or arbitration costs? What might be some of the effects, considering increasing consolidation, bankruptcy and so on?
What legal challenges are we seeing to the NSA from staffing groups? How are these being adjudicated at the federal and state level? To what extent have some of these lawsuits delayed the de facto implementation timeline for the regulation?
How might air ambulance companies respond to regulatory implementation, presuming they have less leverage to increase their in-network footprint? What are the key differences or implications for air transport players?
Are there any major differences in the law for PE-owned and non-PE-owned entities?
How might insurance premiums trend over the next couple years due to the current regulatory climate and why? Would you anticipate any directional move up or down?
How damaged are current payer-provider relationships from the adversarial dynamics of arbitration and some of the media coverage around the bill? How might payers and providers cooperate better to find private market solutions to lower healthcare costs and alleviate some of these pain points?
Is there anything especially important to highlight about the NSA or the payer-provider regulatory environment more broadly?
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