Part II of the No Surprises Act (NSA) primarily focuses on payment resolution processes between healthcare providers and insurers when disputes arise over out-of-network services. Specifically, it mandates that when out-of-network providers deliver emergency services or services at in-network facilities, they cannot bill patients more than the in-network cost-sharing amounts (i.e., copayments, deductibles, etc.). The NSA introduced an Independent Dispute Resolution (IDR) process, where providers and insurers engage in arbitration if they cannot agree on payment amounts.
Key components of Part II include:
- Out-of-Network Payment Disputes: Providers and insurers must first enter into an open negotiation period. If no agreement is reached, they can go through the IDR process where a third-party arbiter chooses between the proposed payment amounts based on factors such as Qualifying Payment Amount (QPA) and other contextual considerations like geographical location and the complexity of services.
- Qualifying Payment Amount (QPA): The QPA is a central factor in determining how much out-of-network providers will be reimbursed, but the methodology for calculating QPA has faced significant legal challenges from providers, leading to court rulings that have paused enforcement of QPA-related audits.
For dentists, particularly those who provide services in emergency or hospital settings, the No Surprises Act means that if they provide out-of-network care at an in-network facility, they are required to follow the same billing protections and cannot surprise bill patients for more than their in-network cost-sharing amount. This could impact dental specialists like oral surgeons who sometimes provide emergency or hospital-based services.
As of 2024, enforcement of Part II of the No Surprises Act (NSA) has been influenced by ongoing litigation and regulatory challenges. While the law aims to protect patients from unexpected out-of-network medical bills, its arbitration and payment resolution processes have faced significant legal hurdles. Notably, the Texas Medical Association (TMA) has been actively involved in multiple lawsuits that have led to the vacating of several regulatory provisions, particularly around the Qualifying Payment Amount (QPA), which plays a key role in resolving billing disputes.
In response to court rulings, enforcement of certain aspects of the NSA, especially related to QPA audits, has been paused until at least May 2024. The delays are due to appeals and efforts by regulatory agencies to revise the rules following court decisions. Despite this, federal audits of insurance payors’ compliance with QPA calculations have already begun, but the broader regulatory enforcement remains on hold.
Additionally, a split in court decisions over the enforceability of arbitration awards has created uncertainty. While one court in Texas ruled that the NSA does not provide a mechanism for enforcing arbitration awards through lawsuits, other courts have upheld such enforcement, leading to differing interpretations of the law across jurisdictions.
Despite these legal complexities, regulatory enforcement is expected to remain relatively light in 2024, as regulators focus on revising rules in accordance with court rulings.
Dentists should monitor these developments, as regulatory enforcement is evolving, and the current pause in QPA audits could affect how these rules are applied going forward.