Surprise billing disputes continue to far outpace federal estimates: CMS

The number of balance billing disputes reaching arbitration is far higher than federal projections suggested, according to new data from the Biden administration.

The Centers for Medicare & Medicaid Services (CMS) issued a report this week looking at the number of surprising billing negotiations that reached the independent dispute resolution (IDR) phase of the No Surprises Act protocols in the first six months of 2023. The agency said 136,111 cases reached IDR in the first quarter and 152,699 reached IDR in the second quarter.

That's a total of 288,810 cases that made it to dispute resolution, according to the report. The agency said this is 13 times higher than its projections for the full calendar year.

The number of cases reaching IDR per quarter is also on the rise, CMS said. The number of disputes reported in the first quarter of 2023 was 24% higher than the number reported in the fourth quarter of 2022, and that number grew again by 12% in the second quarter of 2023.

CMS noted that a small number of stakeholders are driving a large portion of the IDR cases. The top 10 parties initiating IDR accounted for 78% of all cases reaching dispute resolution, according to the report, and these include large practice management companies, revenue cycle management firms and medical practices.

The three parties initiating IDR most frequently are SCP Health, Team Health and Radiology Partners, and they alone account for 58% of disputes across the first six months of 2023, according to the CMS report.

CMS said that providers won in 77% of IDR cases, and health insurers won in 23% of cases. The winning offer was about the qualifying payment amount (QPA) in 82% of resolutions, according to the report.

The report also highlights delays in processing the large volume of claims, fewer than half (134,036) closed in the first six months of 2023. The main source of delays? Parties challenging a case's eligibility for IDR, according to CMS.

The non-initiating parties challenged the eligibility of 106,038 claims in the first and second quarters of 2023, according to the report. Addressing these challenges can be complicated, CMS said.

"These reviews involve complex eligibility determinations that require certified IDR entities to expend considerable time and resources," the agency said.

However, growing familiarity with the process has led to fewer inappropriate challenges, and independent arbitrators are scaling up their operations to manage the demand, according to the report. Just 22% of disputes were deemed ineligible in the first six months of 2023.

"Although the first six months of 2023 were characterized by a large volume of disputes and substantial complexity in determining whether disputes were eligible for the Federal IDR process, the Departments anticipate that the ongoing technical and operational improvements to the Federal IDR process, along with the increasing capacity of certified IDR entities, will continue to increase efficiency of the Federal IDR process," CMS said.