No Surprises Act largely successful in protecting consumers though gaps remain, stakeholders say

The federal No Surprises Act “appears” to be effectively protecting patients from the most frequent sources of unexpected medical bills, though several coverage gaps such as those relating to ground ambulance services are still leaving some patients with hefty bills, according to a new qualitative report.

To get a read on the consumer protection legislation after a full year of implementation, researchers from the Urban Institute and Georgetown University’s Center on Health Insurance Reforms, with backing from the Robert Wood Johnson Foundation, interviewed 32 regulators and stakeholders representing consumers, payers, hospitals, billing companies and other relevant industry subsectors.

These informants “largely agreed that consumers are being well protected from surprise balance bills covered under the law,” researchers wrote in the report.

Regulators highlighted a marked decline in consumer complaints, with one state’s insurance regulators sharing that No Surprises Act-related claims made up just two of the 1,800 total complaints they received in 2022.

Other respondents attributed the decline to “insurers’ and providers’ cooperative efforts to eliminate balance bills and correct them when they occur,” according to the report. They said the few complaints constituting an No Surprises Act violation that did come in were quickly adjusted by “most” providers and payers.

Responses from payers, providers, consumer and employer representatives similarly indicated that protections were in place and complaints had decreased or were often addressed.

“One consumer group, which fielded a significant number of surprise billing complaints from consumers in past years, reported having not received one complaint about No Surprises Act-related surprise billing in 2022,” the researchers wrote. “Similarly, an employer coalition said that before the No Surprises Act, there was ‘enough noise to know there was a problem [with balance billing]; since then, we have no noise in this area.’”

The researchers said it is still too early to make any long-term conclusions regarding the No Surprises Act’s industry impact. They also chose not to seek extensive feedback on the independent dispute resolution process due to ongoing litigation that has so far hampered implementation, they wrote.

That said, the researchers and interviewees acknowledged that some of the limited complaints could be the result of insufficient consumer awareness and literacy. These along with billing lags suggest that continued close monitoring will be needed to gauge the No Surprises Act’s effective protection, they wrote.

There’s also some open lanes ripe for further legislative or regulatory action, chief among these cited by interviewees were ground ambulance services. These bills were initially excluded due to a “mishmash” of state- and local-level regulations and fiscal concerns, though a government advisory committee is set to meet in early May.

“The failure to include emergency ground ambulance services, in particular, means that many patients will continue to be balance billed for out-of-network services they had no choice but to accept,” the researchers wrote.

Other cited opportunities for policymakers to better protect patients from balance bills for out-of-network lab work or imaging services received during a visit with an in-network outpatient provider, healthcare organizations’ occasional use of consent waivers, post-stabilization services after a medical emergency, certain ancillary services (such as neuromonitoring) and emergency services sought outside of traditional emergency departments.