Representatives for both providers and payers say dispute arbitrators are often not following the No Surprises Act, Bloomberg Law reported March 16.
Quick federal guidance is being sought to restart the process where tens of thousands of cases sit unresolved, according to the report. CMS paused payment determinations for items or services furnished on or after Oct. 25, following a court decision that found it "continues to place a thumb on the scale" in favor of insurers. The determinations are paused until HHS, the Labor Department and Treasury Department issue further guidance.
Christopher Sheeron, president of Action for Health, told Bloomberg that because of the logjam in the independent dispute resolution process, independent physicians "aren't getting paid a dime." He also alleged insurers aren't making payments when providers win, and CMS isn't taking enforcement actions.
Mr. Sheeron said that if the process does not get restarted immediately and effectively, "we're going to be looking at the closure of thousands of medical practices around the country." Action for Health supports providers regarding arbitration issues.
Arbitrators are confused about the standards they are supposed to follow in settling disputes, according to Christine Cooper, CEO of Aequum, a law firm that provides services to health plan administrations and participants. She said decisions aren't "consistent with the statutory language or the language carried out in the rules."
Adam Beck, senior vice president of commercial policy for AHIP, a health insurance trade group, told Bloomberg clearer rules are needed to ensure the independent dispute resolution process is a last resort rather than the way "certain providers or certain billing companies or staffing firms handle all of their out-of-network claims going forward."
A CMS spokesperson said the federal agencies "look forward to sharing guidance updates soon," according to the report.