CMS: 'Astronomical' volume of surprise billing dispute cases taking toll on agency

An “astronomical” number of surprise billing arbitration dispute cases is impacting the Centers for Medicare & Medicaid Services (CMS), a top agency official said.

Education and communication are integral to an “orderly transition” in the handling of independent dispute resolutions for out-of-pocket charges, the official said. The agency has grappled with legal issues and implementation hiccups surrounding a controversial process for settling feuds between payers and providers on out-of-network charges.

“We are seeing more than expected number of disputes getting to that last stopgap part, which is the independent dispute resolution part,” said Ellen Montz, director of CMS’ Center for Consumer Information and Insurance Oversight. Montz spoke during a session Wednesday at the AHIP Medicare, Medicaid, Duals & Commercial Markets Forum in Washington, D.C. 

The agency is also seeing a lot of ineligible cases that don’t qualify for the dispute resolution process, which requires a third party to choose between out-of-network charges submitted by the payer and provider. 

These ineligible cases require “a lot of casework, phone calls and back and forth to determine eligibility,” Montz said. 

In response to the “astronomical” number of cases, CMS has been working with provider and payer stakeholders on smoothing out the process outlined in the No Surprises Act, a 2020 law that banned surprise medical bills. 

“The solution is education and communication,” Montz said.

The arbitration process has been a consistent source of controversy even while the No Surprises Act was debated in Congress. 

A 2021 rule implementing the arbitration process drew several lawsuits from the Texas Medical Association (TMA) and hospital groups. The groups charged the administration contradicted congressional intent when it directed the third-party arbiter to emphasize a qualifying payment amount (the geographic average for the service) when deciding between the two amounts. 

An updated rule called for the arbiter to give more weight to other factors but drew a similar legal rebuke from the TMA. A federal judge sided with the group, and the legal battle is ongoing.