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.

• Treating patients as being out-of-network for purposes of cost-sharing, resulting in surprise bills that directly violate the NSA.

• Denying coverage for at-risk patients, including infants in neonatology wards, expectant mothers in delivery, and patients battling cancer.

• Engaging in “shared savings” kickback schemes, in which employer-sponsored health plans are burdened with billions of dollars in additional insurer fees.

• 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.

• Making physicians, other clinicians, and medical groups wait months between receipt of initial payment and “complete” payment.

• Calculating qualifying payment amounts (QPAs) that include “ghost rates” in order to reduce payments to impacted medical specialties.

• Reducing their out-of-network payment rates to physicians – in some instances by 100% or more – since implementation of the NSA.

• Forcing medical practices and hospitals to terminate coverage contracts due to underpayment, including lower rates than paid by Medicaid.

• Doing business with Independent Dispute Resolution Entities (IDREs) despite the NSA’s explicit ban on financial ties with IDREs.

• 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.

• 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.

• 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.

• Denying physician claims that include consultation codes as part of an industrywide coding change designed to cut physician reimbursement.

• Down-coding physician services, without any basis or meaningful explanation, as a means to further cut reimbursement.

• Using medical records requests as a condition to adjudicate a claim and issue payment which, in turn, have served to delay or avoid payment.

• Imposing significantly longer wait times for credentialing and contracting, since implementation of the NSA.

• 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. 

• Utilizing independent and distinct websites, rather than a consolidated document, for the delivery to non-participating providers of requisite information such as QPAs. 

• 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.

• 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.