AHIP, representing insurers, and healthcare providers clash over the No Surprises Act’s dispute resolution process. AHIP’s Jeanette Thornton argues that the process favors initiating parties, while providers like Wellstar Health System’s Jim Budzinski claim it disincentivizes payers from keeping them in-network. A Texas judge’s ruling has halted federal dispute resolutions. Thornton stresses the importance of large, high-quality healthcare networks for payer success and refutes claims of intentional payment withholding. Both sides seek a resolution that balances fairness and transparency in the healthcare payment landscape.
When it comes to the No Surprises Act dispute resolution process, there’s a clear divide between payers and healthcare providers.
During a recent hearing by the House Ways and Means Committee on September 19th, Jeanette Thornton, the Executive Vice President for Policy at AHIP, the insurance industry trade association, voiced her concerns. She argued that the independent dispute resolution process, known as IDR, overwhelmingly benefits the “initiating party,” primarily hospitals and air ambulance companies.
In her opening statement, Ms. Thornton expressed her frustration: “Due to an overwhelming number of disputes and ongoing litigation led by the Texas Medical Association, which has created regulatory uncertainty and frequent interruptions, the Departments have struggled to establish an IDR process that is equitable. The IDR process should ensure fairness for all parties involved, maintain consistent rules, offer transparency in decision-making, and ideally be used infrequently.”
As of September 1st, all federal dispute resolutions are temporarily suspended following a Texas judge’s ruling in favor of the Texas Medical Association. They argued that the dispute resolution process unfairly favors insurance providers.
Testifying before the committee, Jim Budzinski, the Chief Financial Officer of Wellstar Health System in Marietta, Georgia, raised his concerns about the dispute resolution process. He claimed that it discourages payers from keeping health systems within their networks, as they increasingly rely on dispute resolution mechanisms to secure higher payments.
Mr. Budzinski stated, “Wellstar has witnessed firsthand the actions of major health insurers who refuse to negotiate with us, insist on going out of network, and turn to independent dispute resolution. We view this as a glaring example of the flawed implementation of the No Surprises Act.”
In response, Ms. Thornton argued that the success of the payer business model heavily depends on maintaining extensive networks of high-quality, high-value healthcare providers.
She countered, “The notion that health insurance providers deliberately withhold necessary payments from healthcare providers contradicts the core of our business model. While we advocate for a regulatory framework that encourages network participation rather than relying on IDR, when a provider is owed additional payments after the IDR process, we have a strong incentive to consider that provider as a potential partner and make timely payments.”
The debate over the No Surprises Act and its dispute-resolution process rages on, with both sides presenting their cases before policymakers.
