THE ISSUE
Protecting Patient Access from Insurer Abuse
Congress passed the No Surprises Act (NSA) with strong provider support to shield patients from surprise bills while preserving their access to in-network care. Some corporate health insurance companies are acting in bad faith, however, manipulating the NSA in the following documented ways:
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Insurers are depriving patients of access to in-network care by terminating provider contracts, slashing reimbursement, imposing patient cost sharing, denying NSA-covered services, and dodging compliance with the Independent Dispute Resolution (IDR) and Open Negotiations processes.
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These actions directly undermine Congress’ intent in passing the NSA, which prioritizes the protection of patients from surprise bills and preserves their access to in-network providers and treatment.
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As a result, insurers are reaping huge profits and stock market gains by paying out a small share of enrollees’ premiums to providers, reducing payment amounts, delaying their disbursement, and engaging in the “shared savings” kickback scheme for billions of dollars in additional profit.
Protecting Patient Access from Insurer Abuse
Americans for Fair Health Care is working to protect patients, their families, and their communities by making decision-makers and the media aware of common insurer abuses, including but not limited to:
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Terminating contracts and kicking medical groups out of insurers’ networks unless the groups accept deep reimbursement cuts.
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Treating patients as being out-of-network for purposes of cost-sharing, resulting in surprise bills that directly violate the NSA.
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Denying coverage for at-risk patients, including infants in neonatology wards, expectant mothers in delivery, and patients battling cancer.
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Engaging in “shared savings” kickback schemes, in which employer-sponsored health plans are burdened with billions of dollars in additional insurer fees.
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Failing to pay provider claims on a timely basis - or at all - despite NSA’s requirement that clean claims be paid within 30 calendar days of receipt.
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Making physicians, other clinicians, and medical groups wait months between receipt of initial payment and “complete” payment.
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Calculating qualifying payment amounts (QPAs) that include “ghost rates” in order to reduce payments to impacted medical specialties.
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Reducing their out-of-network payment rates to physicians – in some instances by 100% or more – since implementation of the NSA.
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Forcing medical practices and hospitals to terminate coverage contracts due to underpayment, including lower rates than paid by Medicaid.
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Doing business with Independent Dispute Resolution Entities (IDREs) despite the NSA’s explicit ban on financial ties with IDREs.
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Refusing to negotiate in good faith with providers seeking to go or remain in-network, thereby further violating the NSA’s intent to secure in-network access.
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Refusing to extend negotiated fee schedules and instead insisting that medical groups accept lower rates, leading to a sharp drop in collections and compelling groups to terminate.
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Deviating from longstanding practice by blocking medical networks from adding new groups to existing insurance contracts or making it much more difficult for them to do so.
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Denying physician claims that include consultation codes as part of an industrywide coding change designed to cut physician reimbursement.
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Down-coding physician services, without any basis or meaningful explanation, as a means to further cut reimbursement.
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Using medical records requests as a condition to adjudicate a claim and issue payment which, in turn, have served to delay or avoid payment.
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Imposing significantly longer wait times for credentialing and contracting, since implementation of the NSA.
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Being less responsive to medical groups when approached about contract discussions, with many saying they will not negotiate rates at all and some not even returning the groups’ calls.
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Utilizing independent and distinct websites, rather than a consolidated document, for the delivery to non-participating providers of requisite information such as QPAs.
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Failing to utilize required remark codes on payments resulting in manual payor website reviews to determine claim eligibility, adding thousands of hours in administrative work to physicians.
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Requiring manual entry of key claims details to initiate the IDR process, compelling physicians to spend thousands of hours on administrative work to appeal deeply reduced payments.