Emergency ground ambulance services are one of the blind spots of the regulation that could be improved with federal intervention.

The No Surprises Act (NSA) is protecting patients from most surprise bills as intended, but the law's scope fails to protect certain vulnerable pockets, according to new analysis by the Urban Institute and Georgetown University's Center on Health Insurance Reforms, with funding from the Robert Wood Johnson Foundation.

Researchers conducted 32 interviews with federal and state regulators, as well as organizations representing a spectrum of stakeholders like consumers, employers, payors, physicians, hospitals, air ambulance providers, and medical billing companies.

Informants largely agreed that one year after the NSA went into effect, patients are being "well protected" from surprise bills. In one state, for example, insurance regulators said that of the 1,800 insurance-related consumer complaints received in 2022, only two were NSA-related.

Another state regulator was a "little surprise" by the lack of complaints, but "attributes this to insurers' and providers' cooperative efforts to eliminate balance bills and correct them when they occur."

The analysis also found that patients appear to be protected from services that previously left them exposed to surprise billing, like air ambulance services. Additionally, researchers said the NSA is "getting consumers 'out of the middle' of payment disputes between providers and payors.

However, gaps remains in the law for other services like ground ambulance, which one state regulator noted can result in patients being billed nine out of 10 times.

"Although the limited evidence to date suggests that consumers are being well protected from balance billing in the situations covered by the NSA, some stakeholders remain concerned that gaps in the law can leave consumers with unexpected financial liability," the report stated.

"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."

Though researchers say it's too early to determine whether the NSA will "constrain the growth in health insurance premiums and encourage broader provider networks," policymakers need to track provider and insurer compliance for potential billing patterns to address vulnerable areas.

In a survey by Morning Consult, 20% of respondents said they or their family had received a surprise bill in 2022, with another one in five billed after being treated by an out-of-network provider at an in-network facility.

Separate data by AHIP and the Blue Cross Blue Shield Association revealed that while the NSA averted over nine million surprise bills in the first nine months of being a law, it also led to providers submitting over 275,000 arbitration claims—nearly 10 times more than originally anticipated.

New research by Turquoise Health examines the state of price transparency for both hospitals and insurers.

"Price transparency has passed a major inflection point" with there now being no shortage of pricing data by both payers and providers, Turquoise Health CEO Chris Severn said in the company's Q1 impact report.

The analysis finds that as of March 2023, 95% of commercially insured lives are now represented by payer data, while 84% of hospitals have posted pricing data. Additionally, Turquoise scored payers on transparency for all payer machine-readable files based on completeness, size, and parsability.

On the payer side, the report notes that pricing data has come in a lot quicker after the insurer price transparency law went into effect in July 2022 than it did for hospitals following their regulation more than two years ago. And the numbers continue to rise, with Turquoise citing 183 payers publishing data as of March, up from 68 in July 2022, 111 in October 2022, and 170 in January 2023.

However, the report highlights that "healthcare pricing is complex" and that the size of payer data requires refinement and necessary context.

"If the government is aiming to require all insurance companies to publish the rates for all items and services, which we at Turquoise fully support, the output will, by nature, be nuanced and quite large," Turquoise stated.

"Due to this unfortunate truth, the data still requires industry expertise and additional reference data to process and create utility for end users. When left in the hands of the inexperienced, as we’ve seen in some articles from industry outsiders, incorrect and hasty conclusions are drawn."

That is less the case with provider pricing data, which now has 5,383 hospitals out of 6,394 (84%) with machine-readable files and 4,703 (73.6%) with significant negotiated rates. Those figures are up from Turquoise's first impact report released in October 2022, when 4,909 hospitals (76%) had posted a machine-readable file and 4,195 (65%) had negotiated rates.

The rise in compliance will "usher in a transformational era where data will be embedded in revenue cycle workflows, contract negotiations, and become an integral part of running a savvy healthcare organization," Turquoise said.

Severn recently shared some price transparency tips for revenue cycle leaders in an exclusive interview with Healthleaders.

"Make sure that you have a good understanding of the laws and requirements," Severn said. "There are a lot of resources out there that can help you get educated and understand where you and your organization can best focus your time.

"Also, keep an eye on the landscape for information. We’re seeing guidance, training, podcasts, and notice of any changes, such as a recent job aid to assist payers and providers with their Independent Dispute Resolution applications, published nearly weekly."

Severn also gave congressional testimony at the March 28th hearing "Lowering Unaffordable Costs: Examining Transparency and Competition in Healthcare," where he spoke for more government action, including the enforcement of standards.

A study reveals an increased interest among executives to work with third-party partners to support their revenue cycle management.

In large part due to the workforce shortage in the wake of the pandemic, most providers plan to outsource revenue cycle functions, according to a study by CWH Advisors.

The consulting firm surveyed 38 hospital and medical group executives in November and December 2022 to gauge interest in the use of third-party partners going forward.

More than six in 10 respondents (61%) said they expect to make greater use of third parties for offering patient financing options in the next two years, with 63% indicating they were dealing with staffing shortages in their revenue cycle departments.

Only 42% of respondents said they are satisfied with their current patient payment solutions. Improving check-in and payment capabilities are high on the list of areas of improvement for providers in order to offer patients a more retail-like experience, the survey stated.

"We designed this study to get providers' point of view on their patient payment needs, to better understand how technology supports payments processes, and to learn more about how the procurement of those services occurs," David Stievater, partner at CWH Advisors, said in a press release.

"Overall, our research found that providers work hard to balance their financial goals of accelerating cash flow and reducing debt with offering excellent service and flexible payment options to patients."

Kaufman Hall's 2022 State of Healthcare Performance Improvement report found that revenue cycle is the most common area for outsourcing among hospital leaders. Of the 86 hospital and health system leaders surveyed for the report, 27% said they've pursed outsourcing revenue cycle functions, which was ahead of other solutions like environmental services (23%) and IT services (21%).

Nearly two-thirds (65%), of medical billing companies have a positive outlook on the sourced billing industry, according to another report by Tebra. Forty three percent of respondents also said they view outsourcing as a significant opportunity, while 42% see significant opportunities to expand services.

The changes aim to provide consistent access to medically-necessary care while reducing delays for beneficiaries.

Prior authorization policies in CMS' Medicare Advantage (MA) final rule have garnered widespread support from medical and payer groups for streamlining the administrative process.

As part of the rule, prior authorization approvals are required to remain valid for as long as medically necessary, while denials of coverage based on medical necessity must be reviewed by healthcare professionals with relevant expertise before a denial can be issued. MA plans are also required to annually review utilization management policies.

Additionally, the rule requires that coordinated care plan prior authorization policies may only be used to confirm the presence of diagnoses or other medical criteria and/or ensure that an item or service is medically necessary, according to the fact sheet released by CMS. Coordinated care plans must also provide a minimum 90-day transition period when an enrollee underdoing treatment switches to a new MA plan, during which the new MA plan cannot require prior authorization for the active course of treatment.

Here’s how groups reacted to the prior authorization changes in the rule:

American Hospital Association (AHA)

"Hospitals and health systems have raised the alarm that beneficiaries enrolled in some Medicare Advantage plans are routinely experiencing inappropriate delays and denials for coverage of medically necessary care," said Ashley Thompson, AHA senior vice president of public policy analysis and development. "This rule will go a long way in protecting patients and ensuring timely access to care, as well as reducing inappropriate administrative burden on an already strained health care workforce."

American Medical Association (AMA)

"The AMA applauds CMS Administrator Brooks-LaSure for leading the effort to include provisions in this final rule that will ensure greater continuity of care, improve the clinical validity of coverage criteria, increase transparency of health plans' prior authorization processes, and reduce care disruptions due to prior authorization requirements," said Jack Resneck Jr., AMA president. "The AMA has long advocated for such meaningful prior authorization reforms and Medicare Advantage enrollees will benefit from the important new protections."

Medical Group Management Association (MGMA)

"MGMA supports today's action by CMS to finalize its proposals to reign in detrimental prior authorization practices, thereby strengthening the Medicare Advantage (MA) program," said Anders Gilberg, MGMA senior vice president of government affairs. "We are thankful that the agency heeded our call to finalize the continuity of care provision, limiting dangerous disruptions and delays to necessary patient care."

Better Medicare Alliance

"CMS' final policy rule for 2024 will support Medicare Advantage's efforts in bridging the health equity gap and providing high-quality care," said Mary Beth Donahue, president and CEO of Better Medicare Alliance. "Further, we support provisions to streamline the prior authorization process to ensure timely access to care as well as steps to ensure transparency and accountability within Medicare Advantage."