The Emergency Department Practice Management Association (EDPMA) recently shared important data findings related to the No Surprises Act. This release provides valuable insights into the state of compliance and challenges faced under this legislation. Let’s delve into the key findings from the EDPMA report and understand the implications for patients, providers, and insurers.

Reimbursement Reductions Impacting Emergency Departments

One of the significant findings from the EDPMA report is the substantial reduction in reimbursement for out-of-network (OON) claims. In 2023, net collections per emergency department visit for OON claims experienced a significant decline, amounting to a 39% reduction compared to the previous year. These reimbursement reductions pose a challenge for emergency physician groups, exacerbating workforce shortages and increasing strain on medical professionals.

Limited Utilization of the Independent Dispute Resolution (IDR) Process

Another noteworthy revelation from the EDPMA report is the limited use of the IDR process. Out of the eligible OON claims, only 33% underwent the federal IDR process. This suggests that IDR is currently utilized for a minority of OON reimbursement determinations. Various factors contribute to the low utilization of IDR, indicating a need for increased awareness and accessibility to the dispute resolution process.

Reasonable Reimbursement Offers by Providers

The EDPMA data indicates that providers prevailed in 73% of IDR disputes, highlighting the alignment between provider reimbursement offers and the decisions made by IDR experts. This high success rate suggests that providers often offer reasonable reimbursement amounts compared to health plans. The findings resonate with the need for fair reimbursement practices and emphasize the importance of appropriate payment for emergency medical services.

Delays in the IDR Process

A concerning aspect revealed by the report is the lengthy dispute resolution timeline. Only 7.6% of filed disputes have been resolved, with an average dispute age of 211 days, equivalent to around 7 months. These delays significantly impact the resources and cash flow of emergency medicine practices, hindering their ability to negotiate fair in-network rates and provide timely patient care. Addressing this issue is crucial to ensure a more efficient and fair process for all parties involved.

Non-Payment and Underpayment by Health Plans

Furthermore, the data highlights the challenge of non-payment or incorrect payments by health plans. Within the required 30 business days, 24% of disputes resulting in owed payments from health plans were either unpaid or paid incorrectly. This non-compliance poses challenges for physician practice cash flow and undermines patient access to care. Improvements are needed in the payment processes of health plans to address this issue effectively.

Health Plan Non-Compliance with NSA Requirements

Alarmingly, the report reveals that a significant portion of OON claims (82%) did not adhere to the correct calculation of the Qualifying Payment Amount (QPA), and 56% did not include the required inflationary adjustments. This under-reimbursement negatively impacts providers and violates the statutory and regulatory requirements of the No Surprises Act.

The EDPMA report sheds light on the challenges faced by emergency medicine practices and the broader implications for the healthcare industry under the No Surprises Act. It underlines the urgent need for regulatory action and improved compliance to ensure fair reimbursement practices, timely dispute resolution, and sustained access to quality emergency medical care.

The insights and findings presented by EDPMA will undoubtedly shape ongoing discussions and efforts to address the identified challenges. As stakeholders work together to navigate the complexities of the No Surprises Act, it is crucial to prioritize fair and transparent reimbursement practices and uphold the patient’s best interest in emergency medical situations. Stay tuned for further developments as EDPMA and other industry stakeholders continue their advocacy for fair reimbursement and compliance with the No Surprises Act.