"Arbitration Outcomes for Out-of-Network Medical Bills Under the No Surprises Act"

Area of Science:

• Health Economics
• Healthcare Policy
• Medical Billing

Background:

• The No Surprises Act (NSA) aimed to protect patients from surprise medical bills.
• Arbitration under the NSA for out-of-network care may lead to high costs.
• The act's arbitration process is intended to settle disputes between insurers and providers.

Purpose of the Study:

• To analyze payments for out-of-network care resolved through NSA arbitration.
• To compare arbitration settlement amounts with in-network prices and the Qualifying Payment Amount (QPA).

Main Methods:

• Analysis of 7,076 dispute and claims data from Elevance Health in 2023.
• Comparison of insurer and provider bids, settlement amounts, QPA, in-network prices, and Medicare rates.
• Characterization of payments resulting from NSA arbitration.

Main Results:

• Providers won 80% of the analyzed disputes.
• Median arbitration settlements were 3.72 times the QPA and 2.04 times in-network rates.
• Settlement amounts were substantially higher than QPA and in-network prices, and 4.5 times Medicare rates.

Conclusions:

• NSA arbitration settlements significantly exceed expected in-network prices.
• Out-of-network providers receive substantially higher payments via arbitration than in-network providers.
• Findings contrast with Congressional Budget Office predictions of arbitration savings.