EDPMA advocates for the practice of emergency medicine through federal, regulatory and state advocacy. Priority issues include implementation of the No Surprises Act, fixing the Medicare physician fee schedule, protecting EMTALA and keeping patients out of the middle of payment disputes.
EDPMA’s 2024 federal advocacy priorities include:
Reforming the Medicare Physician Fee Schedule by:
- fully offsetting the 3.4% reduction planned for 2024
- providing an annual inflationary update, and
- modernizing the budget neutrality requirement.
- pushing for long-term reform
Continued pressure for the fair implementation and enforcement of the No Surprises Act
- Improving enforcement mechanisms that protect patients and ensure smooth implementation of the law by:
- Creating penalties for payers who fail to meet the statutory payment deadline of 30 days following a determination made by the independent dispute resolution (IDR)entity.
- Creating penalties for statutory violations of patient protections by payers that mirror the penalties for similar violations by providers.
- Providing additional transparency requirements.
Eliminate third-party fees for provider reimbursement (EFT and Virtual Credit Card fees)
Improve network adequacy standards including:
- Standby costs
- National emergency
- Parity
- Commercial Tax
AI and Medical Decision Making
EDPMA Data Analysis: No Surprises Act Implementation and Compliance (April 2024)
Access survey findings and press release.
Key Findings from EDPMA Survey
Reimbursement Reductions
Emergency medicine physician groups experienced a 39% reduction in net collections per patient visit for Out-of-Network (OON) claims in 2023 compared to 2022.
This decrease in commercial health plan reimbursement is occurring despite consistent demands for high-quality clinical care and exacerbates existing workforce shortages and workplace strain. These dramatic declines in commercial reimbursement are occurring against the backdrop of Medicare fee schedule cuts and the lack of an inflation adjustment to the Medicare physician fee schedule.
Limited Use of Independent Dispute Resolution (IDR)
Only 33% of eligible OON claims were submitted to the Federal IDR process. The remaining 67% of eligible claims did not enter the IDR process due to various practice limitations.
The Clinician’s Offer for Payment in OON Scenarios Is Reasonable
Clinicians prevailed in 73% of IDR disputes, closely aligning with the 71% success rate reported by the Departments of Health and Human Services, Labor, and Treasury for Q1 and Q2 2023.
This suggests that, almost three-fourths of the time, an independent dispute resolution expert finds that the clinicians’ reimbursement offers are more reasonable than those of health plans.
Independent Dispute Resolution Process Delays
Only 7.6% of filed disputes have been resolved. The average age of disputes is 211 days (about 7 months).
These delays significantly hamper resources and cash flow for emergency medicine practices and pose significant risks for patients’ timely access to care.
Non-Payment and Underpayment by Health Plans
When IDR disputes result in payments owed by health plans to providers, 24% were either unpaid or paid incorrectly within the 30 business days required by statute.
This level of non-compliance further impedes cash flow for physician practices and undermines their stability, which ultimately risks timely patient access to care.
Health plan non-compliance also undermines the careful balance that Congress created in the No Surprises Act, which provides a process for aggrieved parties to obtain fair reimbursement for clinical services.
Health Plan Non-Compliance with NSA Requirements
82% of OON claims did not attest to the correct calculation of the Qualifying Payment Amount (QPA), and 56% did not include the required inflationary adjustments.
Health plan noncompliance with the No Surprises Act statute and regulation requirements continues to impede the outcomes designed by Congress.
Increased Patient Cost Sharing After Health Plans Lose an IDR Dispute
50% of respondents reported that health plans at times increased patient cost-sharing amounts after an IDR determination.
This practice is one of the most concerning violations of the No Surprises Act, which is intended to protect patients from certain financial consequences of their health care.
Inadequate Government Response to Complaints
EDPMA survey respondents submitted 19,047 complaints to relevant federal departments in 2023, with only 1.3% of these complaints being resolved.
The dramatic lack of response continues to threaten the effectiveness of the No Surprises Act and prevents important dialogue and solutions to recognized problems with the NSA’s implementation.
Network Instability
Many respondents experienced termination of existing in-network commercial health plan contracts, or renewed contracts with reduced rates.
This instability is driven by health plans using non-market-based QPA calculations, forcing physicians out of network or into accepting lower rates, and drives higher utilization of the independent dispute resolution process.
Conclusion
The Emergency Department Practice Management Association and its members fully support the No Surprises Act’s intent of protecting patients from unexpected medical expenses. However, effective implementation requires fair reimbursement for timely, high quality and sustainable emergency care and strict adherence to the law and regulations by all parties, including health plans.
EDPMA calls for enhanced enforcement of the No Surprises Act statute and associated regulations and prompt resolution of compliance issues to sustain the healthcare safety net for all patients. This is not our first call for such essential enforcement, which proves that the ongoing failures in effective enforcement continue to undermine the success of the program.
EDPMA Data Analysis: No Surprises Act Independent Dispute Resolutions – Deficiencies and Compliance Failures
EDPMA surveyed its membership to report on issues related to the implementation of the No Surprises Act (NSA) and its Independent Dispute Resolution (IDR) process since its enactment on January 1, 2022. This data documents our members’ experiences with the IDR process and represents a high-level summary of initial findings and represents at least one-fourth of all emergency department (ED) visits in the United States and prior to the August 3, 2023, closing of the federal IDR portal. See the full report here.
EDPMA’s first and second study reveal:
- 91% of filed claims remain open and unadjudicated.
- 95.6% of outstanding claims are 5+ old from 127 health plans.
- 46% of the time, payers are not responding during the 30-day Open Negotiation period.
- 52% of the time, payers do not acknowledge an IDR had been filed.
- 75% of payers who actually respond in the IDR process do not make an actionable offer.
- 60% of payers are not updating the QPA amounts with the statutorily required inflationary update.
- Payers are not participating in a 30-day open negotiation period and IDR process as expected by statute.
- Rapid and effective enforcement is not happening.
- 87% of payers did not pay in accordance with the IDR Entity decision.
EDPMA offers these solutions:
- Implement the law as designed.
- Congressional involvement
- Rapid and effective enforcement
- EMTALA must now be funded.
EDPMA Data Analysis: Qualifying Payment Amounts and Health Plan Compliance Under the No Surprises Act
EDPMA surveyed its membership to report on issues related to the implementation of the No Surprises Act (NSA) since January 1, 2022.
See the study findings here.
EDPMA’s study reveals:
- 91% of claims surveyed did comply with the NSA’s statutory and regulatory QPA disclosure requirements.
- Post-NSA Out-of-Network Payments decreased 92% of the time, compared to Pre-NSA. The average decrease is 32% per ER Visit.
- The Independent Dispute Resolution volumes are driven by artificially low QPAs, payer intransigence, failure of Open Negotiation, health plan termination of in-network agreements, and CMS’ refusal to implement common sense recommendations.
- When reported, the QPA consistently equals the allowed amount for provider payments.
- Emergency Department staffing is in jeopardy.
EDPMA also offers solutions including:
- Congressional Involvement
- Rapid and effective enforcement
- Accurate QPAs
- Require and Clarify RARC Codes
- EMTALA Must Now Be Funded
See our solutions here.
EDPMA May 2024 Lobby Day
On May 22, 2024, 28 EDPMA members, representing nine states, held 38 meetings with Congressional offices. Our advocacy efforts included:
Requesting Congress to support enhanced enforcement of the No Surprises Act to ensure successful implementation
Urging Congress to stabilize the Medicare Physician Fee Schedule by, at a minimum, provide an annual inflationary update and modernize the budget neutrality requirement.
Urging Congress to reauthorize the Dr. Lorna Breen Health Care Provider Protection Act which provides grants to improve mental health among clinicians.