When the No Surprises Act took effect in 2022, it offered protection for patients against unexpected medical bills from out-of-network providers. However, one lesser-known provision of this law is adding $65 million in annual health care costs for BlueCross customers and members.
The law also established a benchmark called the Qualified Payment Amount (QPA), which reflects the median in‑network rate already agreed to in a market. It was meant to be a fair standard and the default for out-of-network payments.
The No Surprises Act also set up the Independent Dispute Resolution (IDR) process was created as a backstop for health plans and providers to resolve disagreements. And instead of accepting the QPA, many providers use IDR regularly to request much higher payments.
The impact is proving to be significant:
- Providers filed around 11,000 IDR claims against BlueCross last year.
- Those providers are frequently seeking 300-400% of the QPA, with final payments averaging 250%or more.
- IDR is adding $50 million in additional payments to providers and $15 million in administrative costs.
Now, some private-equity-backed provider groups are intentionally leaving or staying out-of-network and using IDR as a revenue strategy to secure payments far above fair, market‑based rates. In fact, a KFF analysis found that the top 3 IDR-initiating practices were backed by private equity firms.
The higher payments driven by IDR claims don’t disappear:
- They show up as higher costs for self‑funded employers who pay their own claims.
- And over time, they show up as higher premiums and out‑of‑pocket costs for consumers.
That’s why BlueCross is continuing to advocate for affordability and for improvements to the IDR process that reflect the law’s original intent: protecting patients without driving up costs for everyone else.
Delivering affordable coverage sometimes means pushing back on pricing practices that aren’t sustainable, because it matters for the businesses and families BlueCross serves.
Scott is responsible for day-to-day management and operation of the state’s largest health insurer. He takes an active role in developing the long-range goals, plans and objectives of the organization, and leads operations teams including customer service, claims, clinical staff, provider networks, marketing, and information systems.