providers successful under the Federal No Surprises Act

---

Over 3,3 million payment disputes have been filed under the Federal No Surprises Act from its inception on January 1, 2022 through May 2025, vastly exceeding the government estimates  of around $17,000 annually. According to a report by the Center of Health Insurance Reforms, not only have providers brought more disputes than expected, they have won the vast majority of the cases and typically received three times the typical in-network rate.  In 2024, providers won 85 percent of the line-item claims decided that year, up from 81 percent in 2023.  CHIR.georgetown.edu

The Federal No Surprise Act, effective January 1, 2022, was passed to prohibit surprise billing in certain circumstances.  Since it was passed however, the law has been subject to various lawsuits and as a result, certain portions of the law were vacated or changed.  In December 2023, CMS published a guidance document so that disputing parties could be better educated on the process.  The document can be found at :https://www.cms.gov/files/document/federal-independent-dispute-resolution-guidance-disputing-parties.pdf

The NJ Department of Banking and Insurance (NJ DOBI)  posted a bulletin  to advise health care professionals that a new act, Ensuring Transparency in Prior Authorization Act (ETPAA) replaces an  older act known as Health Claims Authorization, Processing and Payment Act (HCAPPA) and takes effect on January 1, 2025.  In addition to regulations related to the prior authorization process, the ETPAA also includes provisions regarding the prompt payment of claims, overdue claims, interest, internal appeal mechanisms and the arbitration process under the Program for Independent Claims Payment Arbitration (PICPA).  .