Insurers Now Using “No Surprises Act” to Narrow Coverage Networks and Restrict Patient Access

As the American College of Radiology^® (ACR^®) warned, insurers are now using the Biden administration’s misinterpretation of the No Surprises Act, passed to protect patients during insurer-provider payment disputes for out of network care, to narrow medical networks and restrict patient access to their current providers.

This profit-driven move impacts access to all imaging (not just emergency care), including cancer screenings, use of which plummeted[1] during the COVID-19 pandemic and may yet lead to increased cancer deaths. Scans to measure cancer treatment effectiveness and to diagnose and treat many other conditions are also impacted.

Blue Cross Blue Shield of North Carolina is the first insurer to tell providers they may be considered an “outlier contract” scheduled for “termination” if they don’t accept an immediate, drastic cut in reimbursement for services provided. Many providers — who already are reeling from the COVID-19 pandemic’s economic impact — can’t withstand this profit-driven move. However, the insurer says that the No Surprises Act allows them to take such action.

“Without regard for patient impact, insurers are trying to increase their already record profits by narrowing their provider networks,” said Howard B. Fleishon, MD, MMM, FACR, chair of the American College of Radiology Board of Chancellors. “In addition to ongoing congressional advocacy, the ACR is considering all available options, including legal action, to ensure that the No Surprises Act is implemented as passed by Congress and protects patients’ access to their chosen providers.”

The recent surprise billing interim final rule ignored the law’s intent to set up a fair independent dispute resolution (IDR) process. The law stated that the qualified payment amount (QPA) be one of many equally weighted factors considered during payment disputes. Instead, the administration made the QPA — an unverified rate propagated by insurers — the primary factor in the IDR process. This sets an artificially low benchmark payment, which may not support wider access to care – particularly in underserved areas.

Health insurers’ net incomes and profit margins have grown every year since 2015. Insurers pocketed record profits in 2020 – even as their costs dropped. Meanwhile, insurance premiums continue to rise even as imaging costs have gone down. Record insurer profits have not led to reduced premiums for beneficiaries. There is no indication — nor proof — that insurer profit increases gained via No Surprises Act-related network restrictions would result in lower costs to patients.

“Efforts to implement the fair and equitable independent dispute resolution process, as stated in the law, do not impact patient protections in the No Surprises Act but would help ensure that patients continue to have access to their chosen providers,” said William T. Thorwarth, MD, FACR, CEO of the American College of Radiology.