No Surprises Act Independent Dispute Resolution Outcomes for Air Ambulances

The No Surprises Act (NSA) banned surprise patient balance bills and established a binding arbitration system to resolve payment disputes between insurers and health care providers (eg, clinicians, hospitals, air ambulance organizations) for certain services, including air ambulance transportation. Understanding use and results of this new independent dispute resolution (IDR) system can inform ongoing adjustments to its implementation.

To describe the involved parties and outcomes of air ambulance NSA IDR cases.

This cross-sectional study assessed cases arbitrated through NSA IDR in 2023 as reported by the Centers for Medicare & Medicaid Services. Participants included air ambulance organizations and commercial insurers. Data were analyzed between August 1 and September 1, 2024.

Fixed-wing and rotary transport disputes arbitrated under the NSA IDR system.

The activation components of fixed-wing and rotary transport disputes were evaluated with data from 2 distinct public files: (1) disclosed parties and outcomes relative to qualifying payment amounts (QPAs), the insurers' median of contracted rates for similar services in the region among similar health plans; and (2) monetary measures but without parties. The first file describes the insurers and organizations involved, including their ownership status, as well as the prevailing party and the offers and decisions relative to QPA. The second file describes QPAs, offers, and decisions monetarily and these are compared with Medicare's urban allowed amount.

There were 5678 IDR cases in 2023, comprising disputes for 4935 rotary and 743 fixed-wing transports. Air ambulance organizations offered a mean (SD) of 3.18 (4.20) times QPA, and insurers offered 1.39 (3.89) times QPA. Organizations won 4905 cases (86.4%) at a mean (SD) of 2.95 (4.12) times the QPA. A total of 3478 cases (61.3%) involved organizations owned by private equity investors, and these cases had higher prevailing offers relative to the QPA. Due to data suppression, analysis of financial measures was possible for 2897 of 5983 activation cases (48.4%), among which the mean (SD) QPA offer was $15 561.08 ($9730.97) (3.74 [2.31] times Medicare), and the winning offer was $32 463.70 ($9987.17) (7.82 [2.39] times Medicare).

In this cross-sectional study of air ambulance payment disputes, air ambulance organizations won most cases, requiring insurers to pay more in these cases. Notably, the NSA does not require changes to patient cost-sharing based on IDR outcomes. Assessment of the financial metrics and outcomes of air ambulance cases was limited due to missing and masked information. Continued monitoring of air ambulance IDR cases is needed to assess the impacts of the NSA.