WASHINGTON, DC – Unnecessary and wasteful costs from the federal arbitration process continue to add up for employers, unions and health plans as certain providers continue to overuse and likely misuse the system, according to a new letter to the Trump-Vance administration from The Coalition Against Surprise Medical Billing (CASMB).
The group calls for the administration to address longstanding operational and cost challenges from ineligible claims and the lack of transparency and efficiency with the No Surprises Act’s arbitration process, also known as Independent Dispute Resolution (IDR).
Ongoing misuse within arbitration is rampant, undermining the law’s intent to lower costs for patients and consumers. Streamlining operations, cutting red tape and ensuring the law works as intended are clear examples of where the administration can increase efficiency.
New data from the Centers for Medicare & Medicaid Services (CMS) highlights how providers are overusing and likely misusing the IDR to maximize reimbursements:
- In the first half of 2024 alone, approximately 610,000 arbitration cases were filed, 47% of which came from just four private equity-backed organizations: Team Health, SCP Health, Radiology Partners and Envision.
- Arbitration decisions disproportionately favor providers, who prevail in more than 80% of cases, often securing payments that far exceed the median in-network rate (the qualifying payment amount).
- Providers are also overwhelming the system by submitting ineligible, incomplete or incorrect claims. Of the more than 450,000 arbitration disputes that were closed, nearly 20% were ruled ineligible.
To address these issues, CASMB urges the Trump administration to issue regulations or guidance to:
- Mandate that IDREs provide employers and health plans all the relevant information needed to process payment determinations;
- Prevent ineligible claims —including Medicare, Medicaid, state-arbitration claims, in-network claims, untimely claims, incorrectly batched claims and claims that have already been through arbitration—from being entered into the arbitration portal and prohibit IDREs from issuing payment determinations on ineligible claims and disputes initiated with incomplete or inaccurate information;
- Establish timely processes for correcting or addressing errors on non-eligible claims and a formal process to appeal payment determinations for non-eligible claims;
- Enable auditing of IDR entity performance and holding initiating parties accountable where there is a demonstrated pattern of making false or misleading representations to the government in the IDR process;
- Ensure clear and timely communications to all parties involved with IDR via a dynamic portal maintained by CMS;
- Require and enhance training and oversight for IDREs on the No Surprises Act statute and guidance to ensure compliance and mitigate instances of abuse or misuse; and
- Mandate timely and transparent disclosures on IDR utilization by individual providers, as well as transparency on IDREs’ performance to ensure objective decision-making.
CASMB commends President Trump for signing the No Surprises Act into law and implores the administration to take decisive regulatory action to ensure the law delivers on its promise to safeguard patients and reduce costs for consumers, workers and American businesses.
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