A key group advising Congress on how to prevent surprise bills for consumers after taking emergency transport is skeptical of applying the dispute resolution process that’s the status quo for resolving other out-of-network disputes to ground ambulances.
The No Surprises Act passed in 2020 created independent dispute resolution, or IDR, as the method health insurers and providers have to follow to resolve billing disagreements that used to result in consumers receiving unexpected charges.
Ground ambulances were a notable exception in the legislation, as a large proportion of emergency rides result in surprise bills. However, No Surprises did call for an advisory committee to review options for restricting surprise ambulance bills.
Members of that ground ambulance and patient billing advisory committee in a Wednesday meeting said IDR wouldn’t translate well to resolving billing disputes over emergency medical services.
“I do worry about shoehorning ground ambulance providers into an existing IDR structure where the vast majority of ground ambulance providers would not have the resources or the time to dispute those,” said Adam Beck, SVP of commercial product and employer policy at health insurance lobby AHIP. “I don’t want to create a system where we’re kind of setting folks up for failure.”
IDR is baseball-style arbitration, in which a third-party arbiter picks one payment offer, submitted by either side, as the final payment amount.
In 2023, it cost $350 to initiate dispute resolution, though the HHS is reconsidering that fee after a district judge ruled with providers earlier this month, finding the price made it cost-prohibitive to access IDR for smaller claims. Previously, it cost $50 to kick off the process.
IDR is also time intensive. It can take more than six months for a provider to receive payment after initiating the process.
The investment needed to embark upon IDR would be difficult for most ambulance providers, given their low volume, committee members said.
Roughly two-thirds of ground ambulance providers do fewer than 2,500 transports a year, according to Asbel Montes, managing partner of healthcare reimbursement consultancy the Solutions Group and chairperson of the committee.
Emergency medical services organizations are also mostly public sector entities. It’s difficult to imagine local governments and fire departments having the time and resources to pursue IDR, Loren Adler, associate director of the Brookings Schaeffer Initiative on Health Policy, said on Wednesday.
Other pieces of the No Surprises Act would create difficulties if applied to ground ambulances, committee members argued.
The qualifying payment amount, a metric arbiters consider in the IDR process, is based on the median in-network rate in a geographic area. However, in-network negotiations in the ambulance setting are rare, and rates vary greatly between regions.
To calculate the QPA, there needs to be a minimum of three contracts for the service in question. There are plenty of areas in the U.S. where that isn’t possible, committee members said.
“Only something like 20% of ground ambulance emergency transports are in-network to begin with. So using that as some sort of actual guidepost seems pretty difficult when we’re talking about the ground ambulance context,” Adler said. “It’s also — if you were to look at the network rates that insurers are allowing today across the country, it’s very, very based on what the local regulation scheme is. To cement that in perpetuity I think seems risky.”
What is appropriate?
Committee members seemed to agree that IDR isn’t the solution for protecting consumers from surprise bills following an emergency transport, but didn’t arrive at a final recommendation for how to prevent them.
Other ideas, like allowing state and local authorities to set their own rates, are problematic because there are flaws to relying on amounts that are allowed today, committee members said.
One risk is that payers could raise in-network coinsurance requirements on patients, while still complying with keeping cost-sharing to in-network levels, Adler said.
Letting local rate setting define how much insurers have to reimburse could increase overall costs to the system, according to Patricia Kelmar, director of healthcare campaigns at nonprofit advocacy organization Public Interest Research Groups.
If the committee ends up recommending some sort of benchmarking system, it should enact national standards for what those rates must consider to assure some level of cost containment, Kelmar said.
“I’m just not convinced that letting every community set its own rates is going to get us to a level where we’re assured that the prices reflect the costs,” Kelmar said.
One potential solution would be for the committee to pick specific dollar amounts for codes, or yoke payment to some percentage of Medicare, plus an additional amount for non-transport services like treatment in place, Adler suggested.
Some states and local governments have stepped in to regulate billing on patients, though they don’t have authority over self-funded employer plans.
Some of those tie state-regulated health plan payments to out-of-network ground ambulances to Medicare. Colorado, for example, requires the plans reimburse private ambulance providers at 325% of Medicare rates, and limits how much patients can pay out-of-pocket.
The committee is scheduled to meet again in October and will send its policy recommendations to Congress later this fall.