The No Surprises Act and Consumer Protection In Healthcare (with Josh Schreiner & Michael Mather)

This video provides an in-depth exploration of the No Surprises Act (NSA) and its profound impact on consumer protection, transparency, and compliance within the healthcare industry. Featuring Josh Schreiner, Chief Product Officer, and Michael Mather, General Counsel, of HealthEZ, the discussion highlights how recent regulations are reshaping the future of healthcare, particularly for self-funded employers and their consultants. The conversation delves into the complexities of navigating new mandates, the challenges of data utilization, and the evolving landscape of patient empowerment and cost containment.

The speakers meticulously break down the various components of the No Surprises Act, emphasizing its dual goals: protecting consumers from unexpected out-of-network medical bills and enhancing transparency in healthcare pricing. They discuss the Independent Dispute Resolution (IDR) process designed to resolve payment disputes between plans and providers, noting the significant backlog and litigation challenges it currently faces. A unique aspect of the discussion is the concept of "care coordination" under the NSA, which grants patients continuity of in-network care for up to 90 days when a provider leaves a network during ongoing treatment, posing complex reimbursement challenges for administrators.

A significant portion of the video is dedicated to the "machine-readable files" (MRFs) requirement, mandated by the NSA to disclose in-network, out-of-network, and pharmacy data. The speakers describe these files as "massive amounts of good data" that are practically unusable in their raw, "gibberish" format due to sheer volume and technical complexity. HealthEZ's approach to transforming this raw data into actionable insights through tools like "Easy Choice" for consumer shopping is presented as a crucial step towards true healthcare consumerism. The discussion also touches upon the "Gag Clause Attestation" requirement, which prohibits contractual clauses that restrict access to cost and quality data, further pushing the industry towards greater transparency and accountability.

Key Takeaways:

• No Surprises Act (NSA) Scope: The NSA encompasses patient protections against surprise medical bills (e.g., emergency services, ancillary out-of-network providers, air ambulance), transparency rules (cost comparison tools, provider directories), and reporting requirements (pharmacy drug spend, machine-readable files). Its core aim is to protect consumers from unexpected costs in situations where they cannot make informed choices.
• Patient Cost Protection: In emergency or specific out-of-network scenarios covered by the NSA, patients are only responsible for their in-network cost-sharing, effectively collapsing the in-network/out-of-network distinction from the patient's perspective. The actual payment negotiation is shifted to plans and providers.
• Independent Dispute Resolution (IDR) Process: The NSA established an IDR process for plans and providers to resolve payment disputes for out-of-network services covered by the act. This process mimics arbitration, with a neutral entity picking either the plan's or the provider's proposed payment amount, without compromise, after a 30-day good-faith negotiation period.
• IDR Backlog and Challenges: The IDR process is severely backlogged, with hundreds of thousands of disputes submitted in its first year, but only a fraction resolved. This is attributed to a lack of certified entities, human resource constraints, and ongoing litigation challenging the rules for calculating the Qualified Payment Amount (QPA) and associated fees.
• Care Coordination Mandate: The NSA includes a "care coordination" provision allowing patients receiving care for certain conditions to continue receiving in-network benefits for up to 90 days if their provider leaves the network. This creates challenges for TPAs in determining appropriate reimbursement rates when they lack access to the former contracted rates.
• Machine-Readable Files (MRFs) Complexity: Plans are required to produce massive, monthly machine-readable files containing in-network, out-of-network, and pharmacy data. These files are often too large and technically complex for average users to access or interpret, making their practical utility limited without specialized processing.
• Transforming Raw Data into Actionable Tools: Companies like HealthEZ are taking the raw MRF data and integrating it into consumer-facing tools (e.g., "Easy Choice") and internal advocacy platforms. This allows members and care navigation teams to shop for services, compare estimated prices, and make more informed decisions about care sites.
• Challenges to Healthcare Consumerism: Despite efforts to increase transparency and provide shopping tools, consumer utilization remains low (e.g., 11% for shopping tools). Factors include the overwhelming complexity of CPT codes, the personal nature of healthcare decisions, and the tendency for consumers to choose higher-cost care once their out-of-pocket maximums are met.
• Incentivizing Informed Choices: Plan design can be leveraged to incentivize cost-effective choices, such as offering zero co-insurance for Ambulatory Surgery Centers (ASCs) versus higher co-insurance for hospitals for certain outpatient procedures. Pre-notification and pre-certification processes also enable advocacy teams to guide members toward high-quality, lower-cost options.
• Gag Clause Attestation Requirement: This new requirement mandates that health plans annually attest that their contracts do not contain "gag clauses" or confidentiality agreements prohibiting access to cost or quality of care data. This shifts compliance from passive enforcement to active attestation, posing significant challenges for plans and their service providers.
• Future of Healthcare: Transparency and Enforcement: The industry is moving towards greater transparency across all service providers, aiming to empower individuals with information for better decision-making. Regulators are expected to transition from an initial phase of education and assistance to more active enforcement of these new compliance mandates.
• Impact of Gene Therapies: The emergence of high-cost cell and gene therapies (e.g., $3-4 million per treatment) presents a significant future challenge for health plans, employers, and reinsurance partners, threatening to dramatically increase healthcare costs beyond historical inflation rates.
• Role of Wearables and Data: Health risk assessments, combined with data from wearables and coaching, can empower individuals to make healthier lifestyle changes, leading to significant reductions in long-term medical costs, particularly for chronic conditions like diabetes.

Tools/Resources Mentioned:

• HealthEZ Easy Choice: A consumer-facing tool and internal advocacy platform that uses machine-readable file data to help members shop for in-network and out-of-network services and understand estimated costs.
• HealthEZ.com/NSA: A landing page with information on HealthEZ's NSA transparency and compliance solutions.

Key Concepts:

• No Surprises Act (NSA): Federal legislation enacted to protect consumers from surprise medical bills and increase transparency in healthcare pricing.
• Independent Dispute Resolution (IDR): A federal process established by the NSA for health plans and providers to resolve payment disputes for out-of-network services.
• Qualified Payment Amount (QPA): A key metric used in the IDR process, representing the median contracted rate for a service, around which payment negotiations and IDR decisions are anchored.
• Care Coordination (NSA): A provision allowing patients to continue receiving in-network benefits for up to 90 days if their provider leaves a network during ongoing treatment for specific conditions.
• Machine-Readable Files (MRFs): Large, publicly posted data files required by the NSA, containing detailed pricing information for in-network, out-of-network, and pharmacy services.
• Gag Clause Attestation: An annual requirement for health plans to certify that their contracts do not contain clauses prohibiting access to cost or quality of care information.
• Consumerism in Healthcare: The concept of empowering patients to make informed decisions about their healthcare based on cost, quality, and personal preferences, often facilitated by transparency tools.

Examples/Case Studies:

• Air Ambulance Bills: Cited as a classic example of surprise billing that the NSA aims to prevent, where patients receive unexpected large bills for emergency out-of-network air transport.
• Phoenix Children's Hospital System: An example of a large health system going out of network with a national PPO network, triggering care coordination challenges for patients.
• Outpatient Knee Surgery: Used as an example where performing the procedure at an Ambulatory Surgery Center (ASC) can be twice as cost-effective as a hospital, highlighting the potential for plan design to incentivize lower-cost, high-quality care.
• Diabetes Management Program: A 750-life employer group implemented diabetes coaching, free insulin, and free supplies, reducing annual medical costs per diabetic from nearly $20,000 to $11,000, demonstrating the impact of integrated, multi-faceted interventions.