[House Hearing, 118 Congress]
[From the U.S. Government Publishing Office]




                 HEARING ON REDUCED CARE FOR PATIENTS:
                 FALLOUT FROM FLAWED IMPLEMENTATION OF
                  SURPRISE MEDICAL BILLING PROTECTIONS

=======================================================================


                               56HEARING

                               before the

                      COMMITTEE ON WAYS AND MEANS
                        HOUSE OF REPRESENTATIVES

                    ONE HUNDRED EIGHTEENTH CONGRESS

                             FIRST SESSION

                               __________

                           SEPTEMBER 19, 2023

                               __________

                          Serial No. 118-FC14

                               __________

         Printed for the use of the Committee on Ways and Means






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                                   _______
                                   
                 U.S. GOVERNMENT PUBLISHING OFFICE 
                 
54-360                   WASHINGTON : 2024 














                      COMMITTEE ON WAYS AND MEANS

                    JASON SMITH, Missouri, Chairman
VERN BUCHANAN, Florida               RICHARD E. NEAL, Massachusetts
ADRIAN SMITH, Nebraska               LLOYD DOGGETT, Texas
MIKE KELLY, Pennsylvania             MIKE THOMPSON, California
DAVID SCHWEIKERT, Arizona            JOHN B. LARSON, Connecticut
DARIN LaHOOD, Illinois               EARL BLUMENAUER, Oregon
BRAD WENSTRUP, Ohio                  BILL PASCRELL, Jr., New Jersey
JODEY ARRINGTON, Texas               DANNY DAVIS, Illinois
DREW FERGUSON, Georgia               LINDA SANCHEZ, California
RON ESTES, Kansas                    BRIAN HIGGINS, New York
LLOYD SMUCKER, Pennsylvania          TERRI SEWELL, Alabama
KEVIN HERN, Oklahoma                 SUZAN DelBENE, Washington
CAROL MILLER, West Virginia          JUDY CHU, California
GREG MURPHY, North Carolina          GWEN MOORE, Wisconsin
DAVID KUSTOFF, Tennessee             DAN KILDEE, Michigan
BRIAN FITZPATRICK, Pennsylvania      DON BEYER, Virginia
GREG STEUBE, Florida                 DWIGHT EVANS, Pennsylvania
CLAUDIA TENNEY, New York             BRAD SCHNEIDER, Illinois
MICHELLE FISCHBACH, Minnesota        JIMMY PANETTA, California
BLAKE MOORE, Utah
MICHELLE STEEL, California
BETH VAN DUYNE, Texas
RANDY FEENSTRA, Iowa
NICOLE MALLIOTAKIS, New York
MIKE CAREY, Ohio

                       Mark Roman, Staff Director
                 Brandon Casey, Minority Chief Counsel   
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                         C  O  N  T  E  N  T  S

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                           OPENING STATEMENTS

                                                                   Page
Hon. Jason Smith, Missouri, Chairman.............................     1
Hon. Richard Neal, Massachusetts, Ranking Member.................     2
Advisory of September 19, 2023 announcing the hearing............     V

                               WITNESSES

Seth Bleier, Vice President of Finance, Wake Emergency Physicians 
  Professional Association.......................................     3
James Bobeck, President, Federal Hearings & Appeals Services, 
  Inc............................................................    10
Diane Spicer, Supervising Attorney, Community Health Advocates, 
  Community Services Society.....................................    16
Jeanette Thornton, Executive Vice President of Policy and 
  Strategy, America's Health Insurance Plans.....................    22
Jim Budzinski, Executive Vice President & Chief Financial 
  Officer, Wellstar Health System................................    29

                        QUESTIONS FOR THE RECORD

Member Questions for the Record and Responses from Jeanette 
  Thornton, Executive Vice President of Policy and Strategy, 
  America's Health Insurance Plans...............................   119

                   PUBLIC SUBMISSIONS FOR THE RECORD

Public Submissions...............................................   183


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   REDUCED CARE FOR PATIENTS: FALLOUT FROM FLAWED IMPLEMENTATION OF 
                  SURPRISE MEDICAL BILLING PROTECTIONS

                              ----------                              


                      TUESDAY, SEPTEMBER 19, 2023

                          House of Representatives,
                               Committee on Ways and Means,
                                                    Washington, DC.
    The committee met, pursuant to call, at 10:07 a.m., in room 
1100, Longworth House Office Building, Hon. Jason T. Smith 
[chairman of the committee] presiding.
    Chairman SMITH. The committee will come to order.
    Three years ago, Congress passed the bipartisan No 
Surprises Act to end surprise medical bills for good. American 
patients were in desperate need of these protections, as too 
many had come face to face with medical bills from being 
treated without their knowledge by an out-of-network doctor. It 
left them on the hook for tens and even hundreds of thousands 
of dollars in surprise medical expenses.
    This law has seen success in ending that crisis. 
Unfortunately, the new surprises for patients have come in the 
form of medical staff shortages, longer wait times, and fewer 
choices because of the Federal Government's flawed 
implementation of the law.
    Three years ago, the Ways and Means Committee led the 
bipartisan effort to draft the No Surprises Act. But agency 
rulemaking has unfortunately ignored congressional intent. It 
has created a tilted dispute resolution process that has left 
medical providers paying more to participate in a process that 
often forces them to accept artificially low payments with no 
enforcement guarantee. It has also led to legal challenges that 
have resulted in significant backlogs and left the process 
clouded in uncertainty.
    This law's implementation has made the very problem it 
intended to fix worse, resulting in more medical providers no 
longer covered under health insurance networks. This leaves 
Americans paying more to access fewer doctors than ever before. 
All of this makes it harder for patients to access quality care 
as health care facilities struggle to even keep their doors 
open, particularly in rural areas. Consequently, emergency room 
wait times have doubled since 2020.
    The rules implementing the No Surprises Act have inflamed 
an existing staff shortage in an industry where having too few 
people can be a life-and-death matter. Right now, 600 rural 
hospitals are at risk of shutting down. Left unchanged, these 
Federal rules will continue to lead to less access to quality 
care. Patients are the ones most impacted by closed hospitals 
and long wait times for critical services. Rural and urban 
areas both face a health care shortage.
    At the same time, the agencies have not bothered to 
implement the advanced explanation of benefits, one of the key 
reforms that members of this committee fought to include in the 
No Surprises Act. Part of ending surprise billing is ensuring 
that people know the price of health care services before they 
walk in the door. Before a patient sees their doctor, patients 
should be told how much they will pay for the care they 
receive. And yet patients still have yet to benefit from this 
protection to which they are legally entitled.
    While Congress made strides in stopping surprise medical 
bills, the fallout of this law's implementation demands our 
oversight. And I am encouraged that there is interest from both 
parties in seeing this bipartisan law fairly implemented. It is 
unacceptable that a major win for Americans can be turned into 
a scenario where medical providers struggle to keep their doors 
open, patients lose access to quality care, and the basic 
principle of knowing the price of the care they will receive 
has yet to be realized.
    I look forward to working with my colleagues on both sides 
of the aisle to make the promise of the No Surprises Act a 
reality.
    Chairman SMITH. And I am pleased to recognize Ranking 
Member Mr. Neal for his opening statement.
    Mr. NEAL. Thank you, Mr. Chairman, and I am pleased that 
you have called this hearing this morning.
    And I want to thank our witnesses for being here, as well, 
and I certainly look forward to hearing from all of you.
    I know what Kevin Brady and I intended when we helped to 
write this law. And the implementation so far has been a 
disappointment, despite the fact that we continue to prevail in 
court decisions.
    For too long, millions of Americans have struggled with 
unexpected out-of-pocket health costs that have caused anxiety 
and hardship for their families. When we wrote this law, we 
weren't targeting anybody, we weren't looking for a victim, and 
we weren't being punitive. In 2020, the Ways and Means 
Committee expanded a long legacy of patient-first policies, 
leading the charge to end the uncertainty of surprise medical 
billing. We brokered the No Surprises Act, putting an end to 
surprise medical billing while enhancing consumer protections 
and empowering patients with more information about the cost of 
their care. Unanimously, this committee put out the appropriate 
version of the legislation.
    Ways and Means Democrats continue to want what is best for 
America's patients. That means an accessible, affordable, and 
transparent health care system with robust protections for 
consumers. The No Surprises Act builds on these priorities, 
providing for an impartial, structured process to settle 
payment disputes between insurers and providers with strong 
conflict-of-interest protections, timely decisions, and clear 
criteria for resolution.
    Unfortunately, implementation of this law has strayed from 
Congress and its original intent, especially as it relates to 
the dispute resolution process. When drafting the law, we 
worked to ensure fairness between the parties involved in the 
payment disputes and we carefully specified factors that should 
be considered during the Independent Dispute Resolution 
process.
    The IDR process was developed through robust, extensive, 
congressional consideration in this committee for two years 
before the No Surprises Act took place. As written, this law 
carefully avoids any one single factor unduly influencing the 
dispute resolution process. Despite this consideration, the 
final rule for the No Surprises Act strays from the law as 
written in favor of an alternate approach that overwhelmingly 
favors one factor instead of the more balanced consideration 
that this committee and Congress fully intended.
    Democrats have fought to bolster patient protections and 
build a healthier, stronger America. We delivered the historic 
Affordable Care Act, and now we are raising the first 
generation of Americans who didn't know a life without patient 
protections and the access that we provided and came through 
the Affordable Care Act. Now more Americans have health 
coverage than ever before, and Ways and Means Democrats are 
committed to building on the progress that we have made by 
continuing to lower health care costs and to promote price 
transparency. That is why we delivered the No Surprises Act--
again, in a bipartisan manner--and we will continue to work 
closely with the Administration to ensure this law is 
implemented as this committee and as Congress intended.
    It is time to get this back on track and ensure that one of 
the greatest consumer protection reforms in our country's 
history is fully implemented as the Ways and Means Committee 
intended.
    Mr. NEAL. With that, Mr. Chairman, I yield back my time.
    Chairman SMITH. Thank you, Mr. Neal. I will now introduce 
our witnesses.
    Dr. Bleier is the vice president of finance at the Wake 
Emergency Physicians Professional Association.
    We have Mr. Bobeck as the president of Federal Hearings and 
Appeals Services.
    Ms. Spicer is the supervising attorney at Community Health 
Advocates.
    And Ms. Thornton is the executive vice president of policy 
and strategy at America's Health Insurance Plans.
    And Mr. Budzinski is the executive vice president and chief 
financial officer of Wellstar Health System.
    Thank you all for joining us today. Your written statements 
will be made part of the hearing record, and you each have five 
minutes to deliver your opening remarks.
    Dr. Bleier, you may begin when you are ready.

 STATEMENT OF SETH BLEIER, MD, VICE PRESIDENT OF FINANCE, WAKE 
         EMERGENCY PHYSICIANS PROFESSIONAL ASSOCIATION

    Dr. BLEIER. Chairman Smith, Ranking Member Neal, and 
members of the committee, thank you for the opportunity to 
testify today in this hearing on the implementation of the No 
Surprises Act.
    I am an emergency physician from Raleigh, North Carolina, 
and I currently serve as the vice president of finance for Wake 
Emergency Physicians PA, or WEPA. I am also a member and fellow 
of the American College of Emergency Physicians, ACEP, which 
represents nearly 40,000 members as well as the North Carolina 
College of Emergency Physicians. On behalf of our practice and 
our specialty as a whole, we appreciate the committee's ongoing 
commitment to ensuring the law is implemented fairly and 
according to congressional intent.
    Wake Emergency Physicians is an emergency medicine practice 
serving central North Carolina. Since our founding in 1992, we 
have always been physician-owned, and have never had any 
corporate or private equity backing or interests. Every owner 
regularly works in the emergency department. WEPA currently 
employs more than 200 dedicated emergency medicine specialists 
comprised of about 120 residency-trained, board-certified 
emergency physicians and 95 advanced practice providers. We 
serve in 11 different emergency departments across 4 different 
hospital systems in the region. Four of those emergency 
departments are located in rural communities. Our goal is and 
has always been to be in-network with every payer. And until 
the first regulations for the NSA were issued, we were in-
network with all four major insurance carriers in our area of 
the state.
    To be clear, the No Surprises Act is a critical bipartisan 
accomplishment that removes patients from the middle of billing 
disputes between physicians and insurers, and we strongly 
supported this goal. In an emergency where seconds and minutes 
are often a matter of life or death, patients should never have 
to think about their insurance coverage or whether they will 
receive a bill that they did not expect.
    Beyond these important patient protections, the law 
established an equitable solution to resolve billing 
disagreements, at least in intent. Unfortunately, the 
implementation of the law to date has proven to be 
exceptionally challenging for smaller practices like ours. 
While we have so far been able to weather some of the impacts, 
if these challenges are not resolved we are deeply concerned 
that practice models like ours may not be viable in the near 
future, and access to lifesaving emergency care may be severely 
affected, especially for rural and underserved patients.
    As I noted earlier, WEPA had historically been in-network 
with all major carriers in our region of North Carolina. Most 
of these contracts had been in place for at least a decade 
without any changes or updates. In November 2021, we and many 
other physician groups in the state received a letter from one 
of these insurers demanding significant cuts to our contracted 
rate. The letter explicitly cited the interim final rule on the 
NSA as justification for the reduction and stated that, if we 
did not agree to new payment terms, our contract would be 
terminated.
    Thankfully, this did not come to pass, but we have since 
had two other payers unilaterally terminate a longstanding 
contract. These insurers are now paying at rates that are up to 
70 percent less than our previous contracts for what are now 
out-of-network services. This is just not sustainable for a 
practice like ours. And, if these conditions persist, we may be 
forced to substantially reduce staffing hours, cut positions, 
or potentially even withdraw contracts at certain hospitals.
    Adding to this burden is the fact that the IDR process has 
been virtually inaccessible for small practices once we are out 
of network. Many smaller practices have been advised by their 
billing contractors to avoid going through the IDR process 
altogether, as the costs outweigh any potential benefit. We 
cannot afford to challenge every underpayment when the non-
refundable portion of the arbitration fee is $50, much less 
$350. Even though the government statistics show providers 
prevail the majority of the time over insurers in IDR, to date 
we have only submitted about 400 IDR claims. Batching rules, 
the IDR processing backlog, and cases where payers are simply 
not paying at all have also contributed to this substantial 
burden.
    Now that at least some of these issues have been resolved 
due to recent court decisions and the resulting pending 
regulatory changes, we do hope to re-engage with the IDR 
process when the portal reopens. But all of this takes up 
valuable time and resources that we would much rather devote to 
patient care. We would rather not be forced to submit IDR 
claims. We want to go back to being in-network with every 
payer, and our long-lasting contracts in place prior to passage 
of the NSA show that we always did our best to be in-network.
    WEPA is only one practice, but, sadly, we know our 
experience is not unique. We believe the No Surprises Act 
clearly struck a delicate balance as to not tip the scales too 
far in favor of any party, but the regulations have not been 
consistent with the law that Congress passed.
    Thank you once again for your attention to these issues and 
for the opportunity to be here to share our experience. I look 
forward to any questions you may have.
    [The statement of Dr. Bleier follows:]

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    Chairman SMITH. Thank you.
    Mr. Bobeck, you are now recognized.

  STATEMENT OF JAMES BOBECK, PRESIDENT, FEDERAL HEARINGS AND 
                     APPEALS SERVICES, INC.

    Mr. BOBECK. Chairman Smith, Ranking Member Neal, and 
members of the committee, my name is James Bobeck, and I am the 
president of Federal Hearings and Appeals Services, a certified 
Independent Dispute Resolution Entity commonly known as an 
IDRE. Thank you for the opportunity to speak to the committee 
today regarding the implementation of the No Surprises Act and 
the Independent Dispute Resolution process.
    FHAS is a certified, veteran-owned small business from 
Pennsylvania. We are an accredited, independent review 
organization possessing ISO certification. We are a leading 
provider of arbitration dispute services and health care 
reviews for Federal and state agencies. We have adjudicated 
over 100,000 health care disputes in the past year and over 3.1 
million decisions in the past 27 years. FHAS was one of the 
first groups certified by CMS as an IDRE entity.
    The No Surprises Act prohibits surprise medical billing in 
certain circumstances. Additionally, health plans must make an 
initial payment to providers based on the qualifying payment 
amount, which is the median rate for a particular service. If 
the provider feels that amount is too low, providers can avail 
themselves of the Independent Dispute Resolution process, and 
an IDRE will determine the final payment amount.
    Over the past two years, the Department of Health and Human 
Services, Department of Labor, and the Department of Treasury, 
collectively known as the Departments, have promulgated Federal 
rules implementing various provisions of the No Surprises Act. 
Most notably, the Departments issued rules regarding how an 
IDRE should adjudicate payment disputes.
    The program rules are determined solely by the Departments, 
and the IDREs are required to follow those rules in carrying 
out their designated functions. Most importantly, these 
functions include adjudicating payment determinations based 
upon the parties' submitted offers and supporting evidence.
    Notably, the IDRE must choose either the provider or the 
payer-submitted offer, which is commonly known as a baseball-
style arbitration.
    The Departments published their latest statistics on the 
IDRE process on April 27, 2023. Those statistics cover the 
timeframe from the start of the process back on April 15, 2022 
through March 31, 2023. In that time, disputing parties 
initiated 334,828 disputes. Entities rendered payment 
determinations in 42,158 of those disputes. FHAS alone issued 
13,500 determinations in that timeframe, which represents about 
32 percent of the overall payment determinations.
    Additionally, 39,890 cases were ultimately determined 
ineligible for the IDRE process, and eligible cases primarily 
resulted from parties' non-compliance with the Departments' 
batching rules, which are rules regarding how parties can 
combine multiple cases into one dispute. IDR Entities also 
closed disputes for other reasons, such as the parties may come 
to a settlement of the matter, or they simply withdraw their 
case.
    Throughout the past year, Federal court rulings have 
vacated certain provisions of the Departments' rules. In 
response, we have made on several occasions a temporary 
suspension of the IDRE program, as CMS attempts to formulate 
new rules regarding that process. Currently, the dispute 
resolution process has been suspended since August 3, 2023, and 
during this suspension parties cannot submit new cases through 
the CMS portal and IDREs cannot adjudicate any payment 
determinations.
    The dispute resolution portal must be opened immediately to 
allow dispute filing. Prior to the shutdown, parties routinely 
filed in excess of 40,000 cases per month. Providers and payers 
rely upon the portal's operation to finalize payment 
determinations. Without payment determinations, parties cannot 
resolve their disputes, providers cannot receive any payment 
for their services, and payers cannot render required payments 
to providers.
    Thank you for the opportunity again to appear before the 
committee. FHAS is committed to providing timely arbitration 
services, and we look forward to continued engagement with the 
committee.
    [The statement of Mr. Bobeck follows:]
 
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    Chairman SMITH. Thank you.
    Ms. Spicer, you are now recognized.

  STATEMENT OF DIANE SPICER, SUPERVISING ATTORNEY, COMMUNITY 
          HEALTH ADVOCATES, COMMUNITY SERVICES SOCIETY

    Ms. SPICER. Chairman Smith, Ranking Member Neal, and 
distinguished members of the committee, thank you for holding 
today's hearing to examine the impact of the No Surprises Act.
    My name is Diane Spicer. I work at the Community Service 
Society of New York, or CSS. CSS has been an unwavering voice 
for low-income New Yorkers for over 175 years. CSS administers 
the Community Health Advocates Program, New York State's 
Designated Health Insurance Consumer Assistance Program, 
through a live answer help line and in partnership with over 20 
community-based organizations located throughout the state. 
Since 2010 Community Health Advocates has helped over half-a-
million New Yorkers enroll in and use health insurance, 
negotiate medical bills, and otherwise access free or low-cost 
health care, saving them $180 million.
    As the supervising attorney of Community Health Advocates, 
I have had the unique opportunity to view the implementation of 
both the New York State out-of-network surprise billing law and 
the Federal No Surprises Act.
    In 2014, the State of New York passed the surprise billing 
ban, setting up a baseball-style arbitration that kept the 
patient out of the middle of payment disputes at the urging of 
CSS on behalf of a coalition of consumer advocates. CSS was 
encouraged to see Congress follow New York's model in 2020 and 
ban surprise medical bills for federally-regulated plans.
    We are grateful for the work done in Congress and in our 
home state of New York to address surprise bills. Nevertheless, 
we still field over 20 calls per month from patients with 
questions. The health care system can be extremely complicated 
to navigate for even the most well-versed among us. Advocates 
spend a lot of time helping patients understand the complicated 
rules and processes necessary to determine whether they have 
received a surprise bill and how to appeal to be held harmless.
    Prior to the passage of New York's law, CHA fielded 
hundreds of calls a year from consumers who faced surprise 
bills. A typical case involved the admission of a client to an 
emergency room for painful kidney stones. The emergency room 
transferred the client to the urology department, who performed 
surgery. All of their providers were in-network except the 
anesthesiologist, leaving the client with the classic surprise 
bill. New York's out-of-network surprise billing law addressed 
these classic cases for our state-regulated insurers.
    We at CHA were delighted to see the enactment of the 
Federal No Surprises Act because it made additional 
improvements to what we had already achieved in New York, 
including providing protections against air ambulance bills, 
addressing network directory misinformation, affording 
protections to consumers in federally-regulated ERISA plans, 
and, importantly, covering the circumstances of when a provider 
incorrectly tells a patient that they are in-network.
    Claudia Knafo, a concert pianist who needed neurological 
surgery, is a classic example of this issue. Claudia did 
everything right. She found a hospital and a surgeon who were 
in-network, cleared everything with her insurance, and 
proceeded with her surgery. But her surgeon's office had 
misinformed her that he was in-network when he, in fact, was 
not. She was stranded with a $35,000 bill. Her situation is now 
covered by the NSA, which requires providers to issue notice 
and consent waiver forms in advance of treatment when they are 
out-of-network.
    With that said, our clients still struggle every day with 
the implementation of our state law and the NSA. Specifically, 
the structure of the law leaves patients vulnerable to surprise 
bills in several ways.
    The first, the process of determining which bills are 
covered and appealing a surprise bill, is too complicated for 
many consumers to understand.
    Second, plans do not automatically hold consumers harmless 
for surprise bills, and many health care providers remain 
uneducated about the law and continue to balance-bill patients.
    And third, providers may use the notice and consent form 
inappropriately. Loopholes also remain in the law. For example, 
there have been operational issues with the rollout of the 
notice and consent form waiver. We have seen instances where 
providers use the consent form inappropriately.
    For example, in a recent case a consumer whose primary 
language was not English was told his varicose vein surgery 
would not be performed unless he signed the form. Because he 
needed surgery and did not understand the form, he signed the 
form shortly before surgery and paid a $6,000 deposit out of 
pocket. His plan's explanation of benefits later stated that 
his claim was reduced and, because of the protections of the 
NSA, he would owe only his in-network cost sharing of $18. 
However, the patient already signed the form, and thus it was 
incorrectly required to pay. It will be hard to reclaim this 
amount.
    All of us sign numerous pages of forms when we go to the 
doctor and get procedures, sometimes on electric devices, and 
few of us have the capacity to understand the ramifications of 
signing the form.
    I would like to close by saying we are deeply proud of the 
work we do. Patient confusion around health care costs 
continues to grow, despite Federal and state protections. We 
urge Congress to work together to restore funding to vital 
Health Insurance Consumer Assistance Program, so that together 
we can help improve the patient experience and help them 
through the very complicated processes of determining whether 
or not they have a surprise bill and appeal to be held harmless 
for that bill. Thank you.
    [The statement of Ms. Spicer follows:]


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    Chairman SMITH. Thank you.
    Ms. Thornton, you are now recognized.

  STATEMENT OF JEANETTE THORNTON, EXECUTIVE VICE PRESIDENT OF 
     POLICY AND STRATEGY, AMERICA'S HEALTH INSURANCE PLANS

    Ms. THORNTON. Good morning, Chairman Smith, Ranking Member 
Neal, and distinguished members of the committee. I am Jeanette 
Thornton, executive vice president for policy and strategy at 
AHIP.
    I testified here in May 2019 as this committee and others 
in the House and Senate were debating legislation to end the 
practice of surprise medical billing. As I said then, every 
American deserves affordable, high-quality coverage and care, 
and surprise medical billing was a barrier to that goal. At 
that time, approximately one in five emergency department 
visits resulted in a surprise bill. Going to the emergency 
department or being treated at the hospital meant uncertainty 
and worry not only about your health, but also that you would 
get an unexpected bill that you couldn't afford.
    Enacted with strong bipartisan support in Congress, the No 
Surprises Act had--has resulted in peace of mind and financial 
security. But the promise of the No Surprises Act remains--has 
not been completely fulfilled. Work remains to improve the 
dispute process, lower health care costs, and grow the number 
of in-network providers.
    It is first worth reflecting on how far we have come since 
the No Surprises Act was passed. The No Surprises Act has 
prevented one million surprise bills per month. To put it 
simply, that is 20 million bills since January 2022. Patients 
in every state are protected from most surprise medical bills. 
Bill charges, often exorbitant amounts, no longer dominate as 
the payment demand for out-of-network care. Patients see lower 
and more predictable out-of-pocket costs because of the 
Qualifying Payment Amount, or QPA, is based on the median of 
market rates.
    There is more good news. For nearly 9 in 10 out-of-network 
claims subject to the law, the No Surprises Act works without 
issue. An initial payment is made by the health plan to a 
provider or hospital, typically based on the QPA, and this 
amount is accepted without any dispute.
    The dispute process was meant to be a backstop, a recourse 
for providers and hospitals to utilize in limited instances 
where market rates for health care items and services may not 
be applicable. But today this process is costly, inefficient, 
and heavily weighted in favor of initiating parties, with them 
prevailing in 71 percent of disputes.
    We share your frustration in how the dispute resolution 
process has rolled out. More cases have gone to IDR than were 
ever contemplated, 14 times more, highly concentrated in just 5 
states. Providers are submitting claims that are ineligible. 
The overwhelming majority of claims are from a small subset of 
physician staffing and billing companies and one air ambulance 
company. Repeated litigation from the Texas Medical Association 
and others has created uncertainty and caused repeated starts 
and stops and hindered the regulators in developing a process 
that works.
    Our goal is to have more health care providers, 
particularly facility-based providers, join plan networks so 
that this IDR process is rarely used. The success of our 
business model depends on having large networks of high-
quality, high-value health care providers.
    A lack of sufficient information has at times delayed 
payments. But despite claims to the contrary, this is not 
intentional on the part of health insurance providers. In fact, 
withholding payments really works against our business model.
    We encourage the regulatory agencies to continue their work 
to ensure the Federal process is efficient, reduces ineligible 
claims, and facilitates on-time and accurate payments. It is 
critical that unbiased IDR Entities are evaluating factors in a 
uniform and transparent manner that aligns with the intent of 
the law.
    Thankfully, today patients no longer have to worry about 
receiving a surprise medical bill when they return home from 
the hospital or emergency department. And for when this does 
happen, we believe there is a path forward to make this dispute 
process work as intended in a way that reduces health care 
spending if all stakeholders work together.
    Thank you for the opportunity to testify. AHIP and our 
members appreciate the continued bipartisan commitment to 
protecting patients from surprise medical billing and lowering 
health care costs.
    [The statement of Ms. Thornton follows:]

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    Chairman SMITH. Thank you.
    Mr. Budzinski, you are now recognized.

STATEMENT OF JIM BUDZINSKI, EXECUTIVE VICE PRESIDENT AND CHIEF 
           FINANCIAL OFFICER, WELLSTAR HEALTH SYSTEM

    Mr. BUDZINSKI. Thank you, Mr. Chairman, Ranking Member 
Neal, distinguished members of this committee.
    Consistent with the introduction, my name is Jim Budzinski. 
I am the chief financial officer of the Wellstar Health System 
from the great State of Georgia.
    The Wellstar Health System is a not-for-profit, community-
based, 11-hospital system serving 1.5 million Georgians. The 
Wellstar Health System operates----
    Chairman SMITH. Could you just pull the mic a little bit 
closer?
    Mr. BUDZINSKI. Yes, sir, thank you.
    The Wellstar Health System operates 6 of the state's 20 
busiest emergency departments. We provide more uncompensated 
care than any other system in Georgia, totaling nearly $1 
billion in our last fiscal year alone.
    Wellstar supports the No Surprises Act, which protects 
patients from surprise emergency room bills. However, we 
appreciate the opportunity to share with you the unintended 
consequences of implementation of the Act, which have 
negatively affected the people and communities whom we serve.
    Health plans have been able to narrow their networks such 
that their enrollees often no longer have access to in-network 
emergency care in many of our communities and rely on a broken 
system to lower reimburse--to hospitals below sustainable 
levels.
    One of our biggest problems with the implementation is the 
broken Independent Dispute Resolution process, which 
significantly disadvantages hospitals and health systems. The 
problems are the result of regulatory interpretations that have 
biased the process in favor of health plans, and bogged it down 
such that there is a long wait time for adjudication of 
submissions.
    For Wellstar, the IDR entities have resolved only 7 percent 
of our roughly 8,000 requests for determination. The estimated 
reimbursement on our requests exceeds $40 million, funds owed 
to us by some of the largest health insurance companies in 
America. At this rate, it will take over 20 years to resolve 
all of our outstanding requests.
    We are also concerned that the implementation of the Act 
has also encouraged bad insurer behavior. Now, without 
consequence, insurers are able to sell insurance in counties in 
which they have no in-network hospital emergency departments. 
While the Act intended for hospitals and insurers to work 
together for appropriate reimbursement, health plans are 
ignoring this provision of the law and regulations.
    For example, one national insurer with whom we are out of 
network reduced our reimbursement by nearly 50 percent 
immediately after following the implementation of both Federal 
and state surprise billing laws. This change represented a $50 
million reduction in reimbursement to our organization.
    Further, another national insurer recently threatened to 
terminate our 20-year-plus contract unless we agreed to a 20 
percent decrease in payment. This demand would represent a 
reimbursement loss of over $4 billion over the next 10 years at 
a time when our cost of care has increased because of the 
pandemic over 25 percent due to workforce shortages and 
increases in supply and drug costs.
    While we were able to resolve this matter with only a $1 
billion cut over the next 10 years, this emboldened behavior by 
insurers is not unique to Wellstar, and it is one of the 
reasons for the median health system operating margins being 
negative, as reported by Standard and Poor's just last month. 
For Wellstar, these cuts in emergency reimbursement jeopardize 
the services we provide to our communities, including those 
sole community hospitals in our system, some of which now 
operate at deficits of 14 to $19 million annually. This result 
was not the intent of Congress when it passed the Act.
    Mr. Chairman, Ranking Member Neal, members of this 
committee, we have appreciated the opportunity to share our 
thoughts with you today. Our time together here is limited, so 
I would refer to our written testimony for more information.
    This concludes my remarks, and I would be happy to take any 
questions. Thank you.
    [The statement of Mr. Budzinski follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Chairman SMITH. Thank you, sir. We will now proceed to the 
question-and-answering--answer session, and I will begin.
    Dr. Bleier, one of the areas of fallout that we have seen 
from the flawed implementation of the No Surprises Act is how 
the regulations incentivize health insurers to limit the number 
of physicians with whom they have contract agreements to cover 
their services. What does that do for patients' access to care, 
especially for those living in rural and underserved areas who 
already suffer from a lack of care options?
    Dr. BLEIER. It makes it much more challenging for those 
patients, as well as the providers taking care of them. If 
physicians are excluded and become out of network, basically, 
that reduces their reimbursement. And their reimbursement is 
what covers the staffing hours, adding additional provider 
coverage to those needing emergency departments. And by 
reducing physician hours, physician--emergency medicine 
provider hours, that reduces the care that those patients need. 
So it has a downstream effect, unfortunately.
    Without that additional reimbursement, we aren't able to 
potentially provide the same level of care that we ordinarily 
would want to to those rural emergency departments who are 
already suffering for a number of different reasons.
    Chairman SMITH. Mr. Bobeck, as an Independent Dispute 
Resolution Entity, you have a front row seat to how this 
process is operating. We have heard concerns about how the 
law's implementation has complicated the dispute resolution 
process and has contributed to a backlog of claims. How has 
this process gotten off the rails, and what can be done to 
ensure that dispute resolution ultimately is fair for all 
parties?
    Mr. BOBECK. Mr. Chairman, three big things that we would 
like to say at the beginning are when it comes to some of the 
matters regarding the implementation and then how it moves 
along the process, the words ``misunderstanding,'' 
``miscommunication,'' and ``misinformation'': parties not 
understanding how the process was intended to work; 
miscommunication among the parties about the information they 
need to provide each other to even try to get to reasonable 
offers; and then ultimately, the misinformation that 
occasionally goes out about how they just actually put cases 
into the system.
    The biggest thing that could happen--and it is starting to 
happen right now--is that parties are getting much better at 
formulating their responses, communicating with each other, and 
then ultimately getting more cases eligible for the process and 
decisions being made. Right now, this process still is in its--
just over one year that it has been going on.
    It was set up for a certain amount of cases, and certainly 
that has gone overboard. But at the same time it is set up to 
move forward on this, and parties, providers, and the IDREs are 
working much better together to get cases moving along.
    Chairman SMITH. Mr. Budzinski, emergency department wait 
times have more than doubled since 2020, and more than 600 
rural hospitals are currently at risk of a closure. As a 
hospital administrator, how have you seen the implementation of 
the No Surprises Act affect the ability of hospitals to 
maintain appropriate staff and critical emergency services for 
patients?
    Mr. BUDZINSKI. Thank you, Mr. Chairman. There is no 
question that the implementation of the Act has had impacts on 
organizations such as ourselves. The impact reduces resources, 
and administrators then have to allocate their scarcer 
resources to staffing and other activities. So there clearly is 
a direct correlation. Whenever resources are reduced, then the 
allocation of those reduced resources impact care in some way, 
shape, or form.
    Chairman SMITH. Ms. Spicer, thank you for your work helping 
patients understand our complex health care system. Three or 
more years ago, patients across the country would still be 
receiving surprise medical bills. You have been firsthand--you 
have seen firsthand how the No Surprises Act has largely 
protected patients from this practice. While the implementation 
hasn't been perfect, can you speak to how the law has benefited 
patients?
    Ms. SPICER. Thank you, Mr. Chairman. The law has benefited 
patients tremendously. It goes beyond many--many states don't 
have--didn't have surprise billing laws before the NSA, but 
goes--this--the NSA goes even beyond the protections that are 
in your average state surprise billing law, as in New York's 
surprise billing law.
    Many, many, many of the cases that I had on my help line 
prior to the No Surprises Act were cases that were unaddressed 
by New York's law, specifically network directory 
misinformation. When you call your health plan and you ask them 
who is in-network, or you look at their online directory and it 
is--the information is outdated, hundreds and hundreds of cases 
of consumers who just get bad information from providers or 
plans about the network are now protected.
    And so many more protections in terms of air ambulance, 
also the--just the resolution processes, though complicated for 
consumers to avail themselves of, are available for them to 
appeal surprise bills and even go through the internal appeals 
process and to external appeal with those bills.
    Chairman SMITH. Ms. Thornton, the rulemaking surrounding 
implementation of the No Surprises Act has been subject to 
multiple legal challenges. This has naturally disrupted the 
dispute resolution process, delayed payments, and thrown a 
blanket of uncertainty over the whole law. How are health 
insurers doing their part to alleviate the current backlog of 
claims and ensure that payments are made in a timely manner?
    Ms. THORNTON. Thank you for the question, Mr. Chairman. You 
are definitely correct. All of the repeated starts and stops 
from the litigation, as well as the changes in regulations have 
really created a lot of uncertainty with health plans with 
regard to how they have to plan their staffing and operations 
for when the arbitration process brings--comes back online.
    There is also a concern that when the process does go 
online, there have been such a large backlog of cases that we 
will not be able to meet the required deadlines and payment 
timelines because there is such a backlog and so much within 
the system.
    And finally, you know, we are really concerned around what 
the updated rules will look like, and whether that will mean 
that the process becomes more unbiased towards the--more biased 
towards the providers versus the health plans. I think our goal 
is a very balanced process. We would love to see a 50/50 
outcome, right? Some cases will be decided with providers, some 
to plans, and that means the process is working well.
    Chairman SMITH. So how are health insurers ensuring that 
payments are made in a timely manner?
    Ms. THORNTON. That is a really important question, and we 
understand how important for providers and their cash flow that 
they are getting paid in a timely manner.
    One of the really important things about the Act is that 
you built in the requirement that we have to make an initial 
payment within 30 days. So providers are getting paid upon 
receipt of a claim within 30 days.
    I think what is often at issue here is how quickly health 
plans are making payments as a result of an IDR decision. As I 
said in my statement, there have been at times delays in those 
payments, and that really has to do with some challenges with 
the implementation technology, as well as very difficult 
deadlines and having to go through, in some cases, thousands 
and thousands of lines of code, match it up to our systems, and 
then make those payments on time.
    But we are certainly--really strive to meet the deadlines 
that are provided.
    Chairman SMITH. Mr. Neal is recognized for questions.
    Mr. NEAL. Thank you. Before I begin my opportunity to 
question our witnesses, I want to take a moment to remind 
members of the committee of the role that this committee played 
in ensuring that Congress would pass a strong and balanced 
law--emphasis on ``balanced.'' And that is what we did.
    The idea was, almost like binding arbitration, to make sure 
that people of goodwill and good intentions would try to avoid 
the process at the end, and it would bring them to a better 
decision-making process at the beginning; this was done in a 
bipartisan manner, and it unanimously passed this committee. It 
was a good product that passed out of here because of the work 
of this committee and the product that became law.
    Dr. Bleier, I have heard from many providers across the 
country that implementation of the No Surprises Act has led to 
financial uncertainty. While HHS revises the regulations to 
comply with the law as enacted, other peripheral issues are 
causing financial difficulty. As with implementation of any new 
and sweeping law, there are certainly growing pains. I have 
been pressing HHS at the top all the way through the members of 
the staff on many issues.
    So beyond the need to revise the standard and the dispute 
entities that are trying to comply with the law, can you 
summarize what other issues in the No Surprises Act are 
affecting payments to the Wake Emergency Physicians?
    Dr. BLEIER. Sure. We had been in-network, as a reminder, 
with all of the major carriers in our area for years. We never 
went back to them and asked for an increased rate. Our 
contracts did not have any cost-of-living indexes, no 
inflationary adjustments year over year. They were tied to 
Medicare fee schedules from years before that.
    In addition, we have also seen significant decrease in 
payments from some insurers over the years not only due to 
inflation, but also due to the fact that a lot of the health 
care expenditures are being pushed to patients in high-
deductible plans. Despite that, we never went back and asked 
for more. We have always intended to be in-network with all of 
these providers. Then--with all of these insurers, excuse me.
    Then the No Surprises Act comes out, and suddenly we are 
getting letters from insurers saying, ``You are out of network 
unless you take a 40 percent reduction,'' sometimes more. Since 
the passage of the law, we have been kicked out of network 
unilaterally by two different insurers, and are seeing 
reductions in reimbursement from one of them by 70 percent from 
our previous contracted rates, which we believe were very fair 
at the time, because at no point up until the No Surprises Act 
came out did any of the insurers come back and ask for us to 
adjust our rates. They were evergreen year over year.
    So, because of the No Surprises Act, we have subsequently 
been kicked out of network. We have seen a tremendous decrease 
relative to what we believe were fair market rates. And in 
addition, there is no recourse for action due to the IDR issues 
that have been ongoing.
    So even when we win in an IDR case, we effectively lose due 
to the fees associated with it, and then we do not get paid 
afterwards.
    Mr. NEAL. Thank you. So our intent here was not to be 
punitive, not to pick on anybody, and not to favor one side or 
the other. It was, as I indicated, a balanced piece of 
legislation, I think, to provide ample opportunity to all sides 
of the dispute.
    So, Ms. Spicer, let me thank you for your testimony. I'm 
grateful for the good work you do every day. And you report 
that patients remain confused about whether their medical bills 
are covered or not and, if they are, how much cost-sharing they 
are responsible for. Why do you think patients are still 
receiving bills they should be protected from, and how would 
you suggest that patients help navigate this process to protect 
them from illegal surprise billing practices?
    Ms. SPICER. Thank you for the question. Health plans--
consumers are not always held harmless, as they should be under 
the No Surprises Act. Consumers still receive surprise medical 
bills. And what we do at Community Health Advocates is help a 
consumer who doesn't know they have a surprise bill, but calls 
to say, ``I have a bill I can't afford,'' or, ``Why didn't my 
health insurance pay,'' and then we go through a complicated 
process to help them figure out whether or not it is a surprise 
bill, and to make the plan hold them harmless, go through the 
appeals processes, or complain to the regulator.
    Mr. NEAL. Okay. Thank you, Mr. Chairman.
    Chairman SMITH. I recognize the chairman of the Health 
Subcommittee, Mr. Buchanan.
    Mr. BUCHANAN. Thank you, Mr. Chairman. I want to thank all 
our witnesses for being here today.
    As a business guy for 30 years before I got here, I am just 
looking at everybody talking about the backlog. It is 
outrageous, especially when you are talking about cuts. You 
send a bill in, you might not get paid for multiple years or 
whatever that timeframe is. You know, obviously, it is just 
shocking.
    So, I don't know, is it--are there firms out there? Is this 
frivolous lawsuits? Is it hedge funds? What is driving--Mr. 
Bobeck, you mentioned the idea of 110,000 claims. I can't 
imagine that. But the other gentleman over here mentioned it 
would be 10 years before he might get paid. How do--nobody can 
run a business like that, especially in the whole health care 
field, where a lot of people feel like they are not getting 
paid fairly to begin with. Compound this, you are out of 
business for a lot of small firms, as we talked about earlier. 
But what is your thought on this? What is driving this massive 
amount of backlog?
    Mr. BOBECK. Congressman, just as a brief note, there are 13 
different IDREs, of which we are 1. Although FHAS has received 
81,359----
    Mr. BUCHANAN. But on year 1 there is 130,000 claims you are 
managing?
    Mr. BOBECK. We have received, since the inception of the 
program, 81,359.
    Mr. BUCHANAN. And you are one of how many firms?
    Mr. BOBECK. There are 13 firms, overall.
    Mr. BUCHANAN. What are you talking about, a million--you 
know, millions of claims?
    Mr. BOBECK. So, since the inception of the program--and the 
CMS has not released the latest statistics since March, but it 
is conceivable that by this point it is close to that--but for 
FHAS, we don't have any backlog. The timeline to get a decision 
out by law is 30 business days. We are doing it in only 23 
calendar days. And the reason for that simply is we have a 
large staff who is working around the clock to get these cases 
out.
    We have a sincere, humble understanding and responsibility 
to know that how our cases--the arbitrations we make affect the 
entirety of the provider and the payer system, as well as 
patients. We understand that we need to make these decisions--
ultimately, in any decision we make there is somebody who is 
normally upset. Somebody wins and somebody loses.
    But ultimately, what we suggest is that people continue to 
move forward with the process. We will continue to have no 
backlog. We will continue to make decisions. Program rules 
around it did ultimately--do create backlogs. As noted, the 
program has been on hold since August 3, so----
    Mr. BUCHANAN. But the backlog that has been created, how 
long does it take to get paid under normal circumstances, 
ideally, of the ones that are in the dispute area?
    Mr. BOBECK. When a decision is made, as noted by Ms. 
Thornton, the plan needs to make their payment within 30 
calendar days. However, even before we get the case, most 
likely two to three months has already passed by before we even 
get the case. The parties going back and forth among payments, 
trying to negotiate it on their own. So conceivably, the 
process can take about possibly five to six months. And again, 
that is why we make our standard when we receive a case that is 
23 calendar days to get out, to get those payments moving 
along.
    Mr. BUCHANAN. Thank you.
    Dr. Bleier, let me ask you, there was a point made on 
behalf of the organization you are with or work for or 
something that 52 percent of the payments are not made on time 
or not made at all. Is that what you said?
    Dr. BLEIER. I don't recall that specific number. But if you 
are speaking to our experience with the IDR process, the 
overwhelming majority of the cases--we have only--the IDR 
process has effectively been unaccessible--inaccessible for us 
for a number of different reasons I think everyone is already 
aware of. Out of the 400-plus submissions, I think 20 have gone 
through arbitration thus far. The rest have been unadjudicated, 
haven't been----
    Mr. Buchanan. And how long does it take to go through 
arbitration in a case, normally?
    Dr. BLEIER. You know, I--from our experience, I think there 
is some statistics that say 90 percent of cases or 91 percent 
of cases still haven't been adjudicated after 6 months. I have 
seen some information along those lines. I don't have that 
information in front of me.
    But I can tell you this. The majority of cases that we have 
won, the overwhelming majority of cases that we have won, we 
have received zero payment from.
    Mr. BUCHANAN. Yes, but the other side of that, the time, 
the energy of your executives or employees through that whole 
administrative process, is a nightmare and very costly. And 
then you get paid, and it is not half of what you think it 
should be. So it is challenging.
    Are there any other outside factors that are creating this 
environment in a negative way?
    Dr. BLEIER. You know, I would imagine there are. You know, 
the main issue is it is just inaccessible. And we have been put 
into this position because, again, we have been kicked out of 
network from payers that we were in-network with for years.
    We don't want to access the IDR process, especially given 
what is going on right now. We have no choice. And 
unfortunately, despite that being our only recourse, it is a 
bit of a false recourse for us right now because if we do enter 
that, you know, it takes forever to potentially be adjudicated. 
Number two, often times the--typically, the fees associated, 
especially when they are $350 for the non-refundable fee let 
alone the additional administrative fees that are part of this 
IDR process, far exceed typically our bills in the first place.
    So, if we enter the process, pay the $350 non-
administrative fee, and then win the case, and then not get 
paid on top of----
    Mr. BUCHANAN. Thank you. My time is up. I yield back.
    Chairman SMITH. Mr. Doggett is recognized.
    Mr. DOGGETT. Well, thank you very much.
    Eight years ago, I introduced the very first surprise 
billing legislation in the Congress, and I was inspired by 
stories like the one Ms. Spicer referred to. In my case, a 
Texas woman who did all the checking to be sure she was in 
network,--and then some instrument was used, unknown to her, in 
the course of the surgery and she got a huge bill for that 
instrument, which was out-of-network, or the constituent in 
Austin who got a $4,000 bill for a colonoscopy out of network.
    It took another five years after the bill was first 
introduced, a blitz from private equity companies urging us to 
do nothing, and heavy lobbying before any legislation was 
passed out of this committee or became law. The battle largely 
became between health care providers and insurance companies, 
with some justified claims on each side and some abuses on each 
side that we produce this final piece of legislation.
    And it should come, I suppose, as no surprise today that 
whether the bill is adequately protecting consumers is not 
being fully explored.
    Ms. Thornton, you testified in the very first subcommittee 
hearing we had about surprise billing in Congress. And I note 
your testimony, confirmed by other consumer protection groups, 
that consumers are being protected from about a million 
surprise billings every month as a result of this legislation.
    But today's hearing fails to explore the loopholes referred 
to by Ms. Spicer and others of you, such as urgent care 
centers, ground ambulances, some of the problems that developed 
concerning pathology and lab tests and other areas, and I think 
that is where the focus should be--is why aren't we providing 
more comprehensive protection to consumers?
    Consumers, of course, in a discussion like this, are not 
the sole concern. This Congress has shown a consistent 
inability to address the problem of soaring health care costs. 
It gets talked about a lot. There is finger-pointing and trying 
to blame one party or the other for those soaring costs. But 
when it comes to really doing something about it, and that is 
at stake here, Congress fails to act.
    On the other hand, the notion that a private practice of 
physicians can't be treated fairly is a legitimate concern. Ms. 
Thornton, if I understood your testimony, the way the system is 
now, with all the improvements that may be needed in the 
system, it is the health care provider, are you saying, that 
prevails 71 percent of the time?
    Ms. THORNTON. Yes, that is according to data released by 
CMS.
    Mr. DOGGETT. So really, the question is whether there are 
enough changes that are necessary in the way this law is being 
implemented to increase it so that it is higher than 71 
percent.
    Ms. THORNTON. Yes, we would certainly love to see a more 
balanced process.
    The chairman mentioned the advanced explanation of benefits 
earlier. We certainly think that that transparent process could 
be a potential game-changer to make sure that consumers, when 
they are scheduling services, can make sure that their 
providers are in-network.
    Mr. DOGGETT. One of my concerns is that so often the 
conflict is not between a private medical practice of a small 
group and a giant insurance company, but between private equity 
and a giant insurance company. I noticed that about a third of 
the complaints are coming from one Atlanta-based equity-backed 
private staffing company. Do you have any sense as to why that 
is happening?
    Ms. THORNTON. Well, that is a really great question. I 
think we need to go have a little flashback to why our--why you 
all passed this law to begin with. At that point in time, there 
were certain private equity-backed staffing firms that were 
really using the threat of surprise medical billing to extract 
really high, relative to Medicare reimbursement, rates from 
health insurance providers, right? And that is the reason that 
Congress really took bold action to pass the No Surprises Act.
    Unfortunately, what we are seeing, and the data released by 
CMS does bear this out--that we continue to see a really small 
subset of providers really taking advantage and using that 
arbitration process. You know, it is not the small mom-and-pop-
type of providers that are taking advantage of this. This is 
large, very well-established private equity-backed firms.
    Mr. DOGGETT. Well, I am concerned about the testimony of 
all our witnesses, particularly some of the comments Mr. 
Budzinski made about the cost this has. But it has to be a 
balance, not a phony balanced billing, as occurred and produced 
surprise billing in the past.
    I think we can make some improvements, but the focus ought 
to be on the consumer, first and foremost. Thank you very much.
    Chairman SMITH. I recognize Mr. Smith from Nebraska.
    Mr. SMITH of Nebraska. Thank you, Mr. Chairman.
    Thank you, certainly, to our panel here today for sharing 
your expertise and insight. It is--I think we have got many 
great perspectives here to try to help us take what is 
obviously a bipartisan, I think, achievement previously, and 
look for ways to improve upon what the situation currently is.
    It is disturbing to hear the various data points, and 
certainly delays. And time is money, we know that. And the 
disruption associated with lack of payment, I think, should 
concern all of us. So I hope that we can take away, you know, 
from this timely hearing some solutions.
    Dr., or I am sorry, Ms. Spicer, thank you for your work 
with Community--as a community health advocate. Have you 
observed any patterns that would be disproportionate perhaps in 
terms of underserved areas or rural areas impacted by the 
shortcomings that currently exist?
    Ms. SPICER. We have--in our program we have--some of our 
agencies in the Community Health Advocates Program, they are--
serve communities in rural areas in upstate New York, and we 
have seen problems across insurers for 20 years or more around 
access to care in those rural communities. And so, yes, there 
are--you know, there are still issues that are there and can--
will potentially be worse if networks shrink. They are already 
very, very small in rural areas in New York.
    Mr. SMITH of Nebraska. And so the difficulty of navigating 
the whole process for those you know, from rural areas for 
example, is there anything that stands out to you that we 
should be especially mindful of?
    Ms. SPICER. Just access to help. You know, in rural areas, 
access to everything is a little bit less than in urban areas, 
potentially. So access to help with them for them to--for those 
patients to find in-network providers, understand what costs 
they may be facing if they have to--if they are forced to go to 
out-of-network providers, and access other options like low-
cost care and clinics.
    Mr. SMITH of Nebraska. Okay, thank you.
    Dr. Bleier, can you give us a little more detail about what 
you have observed as unique challenges perhaps that rural 
providers face when complying with the No Surprises 
regulations?
    Dr. BLEIER. Sure. So our overall payer mix is probably 
about 15 percent in general self-pay, and probably about 30-ish 
percent Medicaid. So about 42 to 45 percent self-pay and 
Medicaid, both of which, you know--for self-pay, unfortunately, 
you know, they are not able to essentially, you know, pay 
anything. And Medicaid certainly reimburses at a much lower 
rate than the cost of the care we are providing. And we have 
roughly another 25 percent that are Medicare as well, which is 
also relatively low. And then the rest are commercial.
    And for those rural communities that already have a lack of 
resources in the outpatient setting, often times these patients 
can't get in to see their primary care physicians. They may not 
have a specialist available. In addition, they have limited 
resources to begin with. So they wait and wait and wait. And a 
common thing that we see is these patients present to our 
emergency departments with a true emergency in extremis, things 
that could have been preventable to begin with.
    And when the emergency medicine providers there are also 
suffering under this law, you know, the law itself fully 
supported in bipartisan fashion, but when the law is not being 
regulated in the manner of the legislation itself, that puts 
undue pressure on those groups because they can only spend what 
they bring in on resources. And all of that money for a group 
like ours that we receive in reimbursement goes directly back 
to pay our providers and our staff that helps our providers.
    So in a rural community, when they are already under-
resourced, we are the true safety net of those communities. And 
if we don't--and we are not able to provide the staffing in 
those rural EDs, when there is a crisis that rural community 
will suffer, unfortunately. And it is heartbreaking, as a 
physician, to have to see that. But, unfortunately, those are 
the unintended consequences.
    Mr. SMITH of Nebraska. All right. Thank you, I yield back.
    Chairman SMITH. Mr. Thompson is recognized.
    Mr. THOMPSON. Thank you, Mr. Chairman, and thank you to all 
the witnesses for being here today.
    As has been mentioned numerous times already this morning, 
we passed this bipartisan legislation to protect our 
constituents from surprise medical bills. It was needed. I 
heard in my district offices, my Capitol offices, and probably 
daily--that is not an exaggeration--from constituents who had 
received surprise billing and were having difficulties with 
this.
    As Mr. Doggett pointed out correctly, this has been 
something we have been working on for five years before we 
passed the original bill, and I think it is important to 
acknowledge that our goal of protecting our constituents was 
met by the bill that we passed, for the most part, but there 
are still challenges. And I agree with all the witnesses and my 
colleagues that we need to figure out how to address those and 
make this an even better bipartisan solution.
    I would like to ask about something I have heard from 
providers in my district, and that is that insurers are often 
simply ignoring the timelines for dispute resolution that were 
required by the law that we passed. And I think it is important 
to be clear that when we pass a law requiring payers and 
providers to go through a dispute resolution process, we intend 
for the relevant parties to participate in that process, not 
ignore it.
    Mr. Budzinski, you alluded to this in your testimony. Could 
you talk a little more broadly about the issue of payers 
unwilling to participate promptly in the process, and how we as 
Congress could address that?
    Mr. BUDZINSKI. Thank you, Representative.
    It is a fact that timelines are not being adhered to by 
many parties. Providers are required to hit certain timelines, 
to submit determination requests on a timely basis, and the 
penalty for missing a deadline for filing a determination is 
that that determination request is dead for a provider. End of 
story. It is just gone.
    With respect to other parties involved in missing 
corresponding deadlines, that is no--that is not the case, and 
we would be glad to provide further detailed evidence to you 
and your staff about where insurance companies and IDR Entities 
have missed their timing and still there is no result except an 
increase in inventory of delayed results that we are seeing at 
our Health System.
    Mr. THOMPSON. Yes, I would like to see that data, if you 
could provide that, please.
    Mr. BUDZINSKI. We certainly will, sir.
    Mr. THOMPSON. Thank you.
    Ms. Spicer, you mentioned that insurance plans, at least in 
some instances, fail to automatically hold patients harmless 
for surprise bills. This is a fundamental problem. Holding 
patients harmless was the central point of the law that we 
passed and what all of us wanted to accomplish for our 
constituents. What are some things that Congress can do to make 
sure plans know their obligations and meet those obligations 
under the No Surprises Act?
    Ms. SPICER. Thank you for your question.
    Yes, I have seen on--at Community Health Advocates, on our 
help line, consumers call with classic surprise bills that 
should be covered under the NSA, however, plans are not holding 
consumers harmless for those surprise bills.
    I would say that, you know, there is--health plans get 
coding and information on when a claim is submitted, and should 
know that claims fit certain criteria, and should be paying and 
negotiating with a provider in a way that holds a--holds the 
consumers harmless. This is done for--even before the NSA, 
before New York surprise billing law in certain commercial 
health insurance plans called HMOs. That is what our surprise 
billing law in New York was modeled after, the protections that 
HMO--some protections HMOs--consumers had already in place.
    So I think it is--it should be kind of built into the 
claims system that the health plans can see what kind of claim, 
and whether the claim would be a surprise bill, and hold the 
consumer harmless for that claim.
    Mr. THOMPSON. Thank you. I yield back.
    Mr. BUCHANAN [presiding]. Mr. Kelly, you are recognized.
    Mr. KELLY. Thank you, Chairman, and thank you all for 
coming.
    So Mr. Buchanan and I are in the same business. We sell 
cars. The biggest customer we have in our service department, 
by the way, is the manufacturers. And we have--the health care 
plan for the owner of the vehicle is their warranty. That is 
also the biggest revenue stream we have coming into the store. 
I can't imagine how you are running a business with the 
accounts payable never being paid.
    I have been in a personal situation where--and my wife will 
get mad at me for this, but I think it is important for people 
to understand this--we have a son who is a heroin addict, and 
he was in a halfway house in LA. He passed out on a sidewalk. 
Somebody called an ambulance. They took him to a hospital. I 
kept wondering why he wasn't answering his phone, and the 
reason why is he was in the hospital.
    So eventually, within four days, he got out of the 
hospital, and we had a chance to talk to him. And the reason I 
bring this up is because, unless you have gone through it, you 
can't understand it.
    About two months later we got a bill for $260,000. And my 
wife went absolutely--she says, ``Oh my God, what are we going 
to do?''
    I said, ``I will tell you what I am going to do. I am not 
paying any attention to it at all,'' and it went away. I don't 
know what happened.
    And I don't know how you all absorb the accounts receivable 
that you have on your books that you never receive. It is 
absolutely incredible.
    This invasive species, being government, has got its hands 
into everything, and made it so difficult for normal businesses 
to absolutely survive. I don't get it. I have been in business 
all my life, and the two most important dates of every month 
for me are the 6th and the 21st. And people say, ``Is that an 
anniversary time?''; I say, ``No, that is payday.''
    But we don't always see the revenue stream, so I can't 
understand how can you possibly run the businesses you are in 
when your biggest customer doesn't pay the bill?
    And I talk about--we talk about wonderful things that we 
are going to do legislatively, and that is all good. We can put 
it out there. But following the model is incredible. I would 
never take advice, by the way, from the company that was $33 
trillion in debt. I would say there is probably not one of the 
plans I want to follow. But you have--so complicated.
    So you can't fix something with nothing. Now, Dr. Bleier, 
you--in many ways--to a young man that grew up in Wisconsin and 
then went to Pittsburgh. His name is Rocky Bleier. Is that 
somebody that----
    Dr. BLEIER. My grandfather would tell me that I was fourth 
cousins.
    Mr. KELLY. Okay.
    Dr. BLEIER. I don't know if I have a----
    Mr. KELLY. Yes.
    Dr. BLEIER. I can't verify that.
    Mr. KELLY. Well, you know, the fact that you take time out 
of your life to come here today and try to help us understand 
what we don't understand and how the policies that were well-
intended are actually not working and that your business model 
is a business model that is totally unsustainable, I don't know 
how rural hospitals exist anymore. It is incredible--when you 
don't have the people on the shelf that could service the 
patients that come in. And I think what they mostly rely on now 
is just emergency care because they don't have people that can 
handle more complicated issues, and there is just no people out 
there to do that anymore.
    If you could just give me a hint, just a little, what is it 
that we could actually do?
    It is nice that you came in here. It is nice that we are 
talking back and forth, but I don't know. I still--if I was at 
the dealership, the first thing I would look at every, every 
day is our accounts receivable. And the ones--if they were over 
90 days, write them off, they are not coming back. They are not 
coming back to get anything from me, and we are never going to 
see them again, but they walked away, you are on the hook for 
what it is that they have done. We had to pay the mechanic that 
did the work, and we have to pay the parts department for the 
parts we put on.
    So what is it that you can do? Because I will tell you 
what, it is incredible today, the accounts receivable that we 
are all trying to balance out. You are graced with the fact 
that the government now is involved in it. So I--that is an 
eye-roller. But what could we do? Just simply tell us what we 
could do to help you.
    Dr. BLEIER. I would say some different things.
    Number one, you know, we are the safety net for the health 
care community, you know, for the health care system across the 
country. And we take care of patients under the most adverse 
circumstances, when they are most vulnerable, as I am sorry to 
hear about your experience, you know, from your family.
    Mr. KELLY. Thanks.
    Dr. BLEIER. But I think that, you know, some type of 
reimbursement for unfunded care would go a long way to 
providers who take care of those patients.
    And I would say, with regards to the NSA, some enforcement, 
enforcement that insurers are calculating the QPA correctly and 
enforcement in teeth that they abide by the arbitrator's 
decision and submit payments to providers or hospitals----
    Mr. KELLY. Yes.
    Dr. BLEIER [continuing]. When the ruling goes in that way, 
because right now there is just no enforcement, even though it 
is a great bipartisan piece of legislation. And that is--that 
is my concern.
    Mr. KELLY. Yes, my time is running out, but I got to tell 
you, I don't know how you do it. I don't know how you write off 
in your accounts receivable of things you never receive. It 
becomes a taxable event for those that don't pay it, I think. 
But we don't--and I don't think we enforce that. But I want to 
thank you for everything you do. It is incredibly important, 
what you do, and the fact that you face an unbelievable, 
complicated business model. I don't know how you do it. God 
bless you. Hey, thanks for coming in today.
    Chairman SMITH [presiding]. Mr. Blumenauer is recognized.
    Mr. BLUMENAUER. Thank you, Mr. Chairman.
    And I must say, Mr. Kelly, I appreciate making it 
personal--I know that is not easy, but it helps give the 
committee a sense that there are human consequences.
    Mr. KELLY. So, Mr. Blumenauer, you and I understand each 
other, and Ranking Member Neal, the things that we go through 
personally, I think we sit up here and somehow we don't 
connect. And I say to people, yes, we do connect with you 
because we go through the same thing. I wish we were the only 
family that had that problem. It is incredible. And especially 
mothers. They can't walk away from it. They just can't. And it 
is really--all you do is just keep supporting them. And I think 
that is what we do.
    So I appreciate your comments. And I--my wife is going to 
kill me for talking about this today, but I got to tell you, 
until you actually go through it--you know how when you are 
little, when you are growing up, and your parents would tell 
you, don't touch the stove, it is hot? Everybody has to touch 
the stove. You don't know it until you get burnt.
    So it is good being with you, sir.
    Mr. BLUMENAUER. Well, I appreciate the reminder that, in 
the final analysis, we are talking about people, and there are 
areas, regardless of our differences, that we can come 
together.
    This legislation was actually an example of coming 
together. It has largely solved the problems. But we have heard 
today from witnesses that it hasn't gone far enough, and there 
are things that are head-scratching. And I appreciate the chair 
and ranking member bringing this back before us, because we 
ought to have a commitment to follow through on a good start. 
We ought to do better. And I would think that there is a chance 
to do that. And the witnesses have helped give me a better 
sense of the shortfall.
    Mr. Bleier, I mean, you explained that the majority of the 
cases you won, there was zero payment, and that the bills are 
often more than they are worth. Can you talk for a moment about 
that dynamic, and what you think we could do to help you move 
that forward?
    Dr. BLEIER. Yes, I appreciate that.
    You know, I think enforcement of the legislation would go a 
long way. I think that a lot of groups are--like ours are 
forced to enter the IDR process.
    Mr. BLUMENAUER. Yes.
    Dr. BLEIER. We have no choice. We have been kicked out of 
network from contracts that have been standing for up to or 
more than a decade with unchanged reimbursement rates. And, 
because we are kicked out of network, we are forced to go 
through the IDR process.
    Right now, we have no leverage with the health insurance 
companies. We can't--we want to go back into network. And 
initially we received, for example, a 40 percent reduction. We, 
a few months ago, went back to one insurer and said, hey, can 
we go back in network? We had a 60 percent reduction.
    So until there is enforcement and, you know, I think that 
the insurers are forced to pay in--consistently with the 
arbitration ruling, we will be at a disadvantage, and this 
process will continue.
    Mr. BLUMENAUER. And I would appreciate, if you have some 
thoughts about ways that we can implement that, what you said 
makes sense. I don't want to do it now, because my time is 
almost up and I have another question, but your thoughts and 
observations about what would make a difference for practices 
like yours would be very useful.
    Mr. Budzinski, you talked about large insurers who refuse 
to negotiate. Could you elaborate on what you think we can do 
to try and remedy that, to make sure that people are playing by 
the rules, operating in good faith, and doing the roles that 
have been assigned to them?
    Mr. BUDZINKSI. Thank you, Representative. I think the 
number-one framework of this phenomenon is that--the unintended 
consequences of how the Act has been implemented is large 
insurers no longer need to have emergency departments in 
network in the counties where they sell insurance. They are 
selling insurance in counties where they don't have any 
emergency departments in network. How is that possible?
    The reason is they don't have a need to have an in-network 
emergency department. They don't have to negotiate with a 
hospital or a health system or a physician group because they 
can use the No Surprises Act process as it is currently being 
implemented to pay in-network rates for out-of-network care. 
And that has never been the case in the last 30--I have been in 
the health care finance business for over 40 years. That has 
never been the case.
    Out-of-network care, because of its uniqueness, is always 
reimbursed, historically, at greater than in-network rates 
because, with in-network rates and discounts, there is always 
an expectation of more volume, and therefore more discount. 
With out-of-network care, all elective care is steered away 
from you, and now you are left with only emergency care.
    So I think that the solution to this is require that--under 
the Act, that the initial payment being made by insurance 
companies meets a minimum level that is consistent with 
historical out-of-network payment for emergency services.
    Mr. BLUMENAUER. Thank you, sir.
    Chairman SMITH. Mr. Schweikert is recognized.
    Mr. SCHWEIKERT. Thank you, Mr. Chairman. And Ranking Member 
Neal and the chairman and many of us have been around from the 
beginning of the debate and discussion on this, so I want to 
walk through and make sure I am listening--sometimes something 
I don't do well.
    The discussion is almost--has two ends on this. Some of it 
is the actual administering of the law, of the rules as it is, 
how long it is taking the bureaucrats, the time, and some are--
maybe some of the game-playing has happened from the 
Administration's rule-drafting and those things of what we 
thought we were getting compared to how it has been drafted.
    Setting that aside--and Mr. Bobeck, forgive the nature of 
the question, but I am going to beg of you, be as brutally 
honest with me as you can. If the rule set is saying, okay, 
here are the rules, that this is an out-of-network--this is, 
you know, what--the arbitration, why can't you and I just 
automate that? Why can't we just write computer code that says 
here is the market area, here is what it is, and here is--and 
it is spit out?
    Tell me where my--and it is not AI. That would actually 
technically be even more an algorithm with constant updating of 
the data. Why can't I completely automate this?
    Mr. BOBECK. Congressman, thank you for the question. AI 
relies upon one thing to do those algorithms, which is set 
data. The data is not set in this particular case.
    Our firm, since its inception, its founders, told us there 
is a very important piece of technology that we have to rely 
upon that has been helpful for us through this process, and it 
is called the telephone. We have to continually talk with the 
parties to make sure that they understand what are they dealing 
with.
    When parties want to submit a claim, many times the 
provider doesn't even know which health plan that they are 
trying to dispute. They are not even quite sure who they have 
to tell that they would like to dispute. They are not quite 
sure of the evidence they have to provide. And the same thing 
on the payer perspective as well.
    Mr. SCHWEIKERT. But Mr. Bobeck, in many ways, you are--and 
I want to make sure we are not crossing each other, but that is 
actually where automating it--check, check, put this in, check 
this--I mean, the hyper-standardization. You could take away my 
friend from Georgia's time problem and filing problem. It is--
and collapse the--actually, some of the cost, but also the 
speed. Why can't we ultimately--because picking up the phone--
it is friendly, and you and I know how inaccurate a 
conversation can be.
    Mr. BOBECK. Thank you. Ultimately, since the program has 
been involved for one year, parties are still getting to 
understand the process.
    But I will say this. Where parties provide the right 
information, you are exactly right, the process goes much 
faster. Processing decisions can be made in less than two 
weeks, and that is frequently happening right now.
    CMS, I cannot speak for them, but I do know that, through 
the portal that they have created, they have continually made 
improvements, and they have more improvements to make, which 
will automate many parts of the process. They did not put that 
out in the first model. The first model is simply to get it off 
the ground.
    But you are exactly right, that those are future 
improvements that can be made, they will be made, and they will 
make the process much more seamless and, I will say, very cost 
effective for everybody.
    Mr. SCHWEIKERT. Thank you, Mr. Bobeck.
    Mr. Chairman, maybe as we start to have our discussions, 
our bipartisan discussions on the side, the--finding out where 
we do not believe the rule sets fit our vision, okay, fine, 
that may require us to push some letters or do some statutory. 
But what we should also maybe have an interesting discussion is 
what would make this as seamless as possible. That if there is 
going to be a dispute, it moves fast, quick, efficiently, 
inexpensively. And that may be making it very clear that 
technology can be the arbitrator.
    And with that, I yield back.
    Chairman SMITH. Mr. Pascrell is recognized.
    Mr. PASCRELL. I thank the witnesses.
    Surprise medical bills were once on the top of the list of 
expenses Americans really do worry about. Whether it is an 
emergency, an inpatient case, or inpatient care, Americans must 
be protected. We came to that conclusion.
    Despite the tired promises, insured patients keep facing 
lawsuits, wage garnishments, garnishments for medical debt. 
That is pretty gross. In fact, it may be outrageous. But it is 
unacceptable.
    So, in 2020, when committee Democrats enacted the 
bipartisan No Surprises Act to protect patients, it was a law I 
believe was carefully crafted to take patients out of payment 
disputes. I remember back in that debate.
    The Administration must implement the law as Congress 
intended, no ifs, ands, or buts. Our law was designed not to 
jeopardize patients and tilt the scales for industry. 
Regulations that avoid these goals are not going to help the 
patients. I don't think we are of like mind about that issue. 
Patients need transparency provisions fully implemented, and 
the law must be followed.
    So, Dr. Bleier, yes or no, do health plans that fail to 
follow binding dispute resolution decisions that collect 
interest on money owed to physicians threaten physicians' 
financial stability? Yes or no.
    Dr. BLEIER. Yes.
    Mr. PASCRELL. Dr. Bleier, yes or no, should there be a 
financial penalty on an entity that fails to pay within the 30-
day required time period?
    Dr. BLEIER. Yes.
    Mr. PASCRELL. So, quickly explain how health insurers 
issuing timely payments can help ensure patients retain access 
to physicians. Give me a quick explanation, if you will.
    Dr. BLEIER. If physician groups and emergency medicine 
groups are reimbursed promptly, it allows them to have the 
resources needed to take care of patients in any environment, 
including rural environments, with less advantageous payer 
mixes where perhaps they have a disproportionate number of 
Medicaid and self-pay patients. And by increasing those 
resources, I think the patients will get much better care.
    Mr. PASCRELL. Dr. Bleier, in August of this year, the 
courts stepped in to resolve guidance disputes for the 
Independent Dispute Resolution that could have increased 
administrative fees by 600 percent. Remember that. What is the 
negative impact of higher administration fees, Dr. Bleier?
    Dr. BLEIER. The higher administrative fees, both the non-
refundable and potentially refundable if you win, often times 
greatly or significantly outsize the professional side or 
provider side bill. So----
    Mr. PASCRELL. And therefore?
    Dr. BLEIER. And therefore, it precludes us from entering 
the process.
    And even if we win a dispute, we often times lose because 
of the non-refundable portion of those fees.
    Mr. PASCRELL. Does that make sense, Dr. Bleier?
    Dr. BLEIER. I think--I hope so. Yes. Not always, but yes.
    Mr. PASCRELL. And what is the impact of the higher patient 
fee access? What is the impact?
    Dr. BLEIER. From a patient perspective?
    Mr. PASCRELL. Yes.
    Dr. BLEIER. So again, you know, an independent group like 
ours, we have no private equity backing. We have zero debt. If 
reimbursement levels fall, and that is--can be through higher 
expenses associated with fees, then we have fewer resources to 
allocate towards what we really want to allocate our resources 
towards: our providers taking care of patients at the bedside. 
If we have less reimbursement coming in, we have less to staff 
and provide those resources.
    Mr. PASCRELL. How deeply is private equity involved in 
this?
    Dr. BLEIER. It is hard for me to say. In our experience we 
have never had any equity backing, so I really can't speak to 
that. We have been an independent group since 1992, so it is 
hard for me to say, sorry.
    Mr. PASCRELL. Mr. Chairman, thank you for your time.
    Chairman SMITH. Thank you. Dr. Wenstrup is recognized.
    Mr. WENSTRUP. Thank you, Mr. Chairman. I appreciate all the 
input today from all the people on the panel and our members. 
And I want to thank Chairman Smith and Ranking Member Neal for 
having this hearing today.
    You know, when we put together the No Surprises Act, we 
worked with all of the doctors in Congress, Republican and 
Democrat, who I might say, if I can, the real protectors of 
patients in this world. And we considered patients first. We 
wanted to alleviate their anxiety by taking them out of the 
equation. I can tell you firsthand there are some times when 
patients worry more about their bill than they do their 
illness. And we wanted to take that anxiety away. It is very 
important in the healing process.
    We thought about providers who just want to help patients 
but get reasonably paid for the work that they do, and go on to 
see the next patient, and help the next one, and not spend a 
lot of time in arbitration and other areas.
    We thought about insurers. We wanted them to be able to pay 
a reasonable fee so that they can stay in their ability to 
insure those that they claim to protect, and that they will 
have providers, especially quality providers.
    We created a system that we believed would lead doctors to 
want to be in-network and lead insurers to strive to have 
doctors in-network, and provide their patients with a quality 
panel, and a reimbursement to providers that was respectful of 
the care that they rendered to the patients, and to fulfill the 
promises made to the patients that they insure.
    You know, I can remember once I had a patient in tears in 
my office because she said, ``I chose this plan because they 
listed you as a member.''
    I said, ``We haven't been in it in three years.''
    That was some of the motivation right there for getting 
some of the changes made into this bill, that insurance 
companies could no longer give false advertising, basically, 
saying, ``This is our product,'' when it wasn't. That is what 
was happening.
    And we go through the process where a patient wants to know 
what their elected procedure is going to cost. We ask the 
insurance company, and they say, ``You have to perform the 
procedure and then bill it first.'' Oh, that is a real doozy 
for the patient that you claim to protect.
    You know, Dr. Budzinski, you talked about out-of-network. 
Out-of-network always paid more. Patients always had to pay 
more out-of-network. They knew that, and they made that choice 
willingly. Those were the rules. You have summed that up very 
well.
    And when--you know, here, when it looked like one committee 
was going to go ahead and have a benchmark, well, what 
happened? We have the documents. Insurance companies 
immediately started sending notices out to doctors saying, ``We 
are going to reduce your fees,'' because this was going to work 
for them. Providers got the letters. We have got them.
    Dr. Bleier, you talked about what is happening now because 
of this. ``We are going to cut your fees, we are going to cut 
your fees.''
    I mean, in situations like we have now doctors quit taking 
calls. I was in a large orthopedic group. You just say, ``We 
can't afford it anymore,'' because--especially if they are out-
of-network. We know what is going on. And without doctors, what 
is your product?
    So why are we going towards this? And at a time when HHS 
and other agencies, they get a cost of living increase, doctors 
are getting paid less under Medicare. And all this just makes 
it worse and worse and worse. And these are the ones that 
actually provide the care.
    I asked the rhetorical question, ``Who would have the 
motives to change the clear intent of the law that we have 
discussed today, and why? And what were the arguments that were 
made? Who had the influence for these changes?'' It certainly 
wasn't Congress, because we made it very clear.
    I will submit for the record the three letters that we sent 
to HHS before the rulemaking process, giving it--spelling out 
the clear intent. We had a Zoom call with HHS, Labor, and 
Treasury, spelling out the intent before the rulemaking 
process. Bipartisan, we did this.

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    And I might add that until Dr. Ruiz, who was on the call, 
an emergency physician, until he spoke up, they wouldn't even 
show their faces on the Zoom call. And he said, ``Would you 
mind showing us who you are?''
    And we asked who made the decision. Nobody could answer 
that. Who was--who really made the decision? Who made the 
argument?
    I mean, Ms. Thornton, I would imagine, I would guess that, 
in the comment and rulemaking process, that your organization 
and others affiliated with you probably made comments to HHS 
and others, right?
    Well, my only question to you is would you mind sharing all 
the communications that you had with HHS, Labor, and Treasury 
concerning this topic? Would you mind sharing those with 
Congress?
    Ms. THORNTON. Yes, we are happy to have conversations with 
your office about that.
    Mr. WENSTRUP. Well, I would like to see your actual 
communications that you sent. I appreciate that. Thank you.
    Chairman SMITH. Thank you. Mr. Davis is recognized.
    Mr. DAVIS. Thank you, Mr. Chairman, and thanks to all the 
witnesses for a very serious discussion.
    You know, when we passed the No Surprises Act into law, it 
was designed to protect patients from predators, surprise 
medical billing, establish a third-party mediation process 
called Independent Dispute Resolution to determine the amount 
of money doctors will receive for their health care services to 
patients from insurance companies.
    The problem is often profits versus greed.
    The law uses an IDR process as a framework where payers and 
providers negotiate and submit offers of what they believe is a 
responsible, reasonable payment for medical services. And the 
arbiter considers the qualifying payment amount, or OPA [sic], 
to be paid to doctors. The arbiter, by law, is to consider a 
range of factors, including a measure of median in-network 
contracted rates for the health plan, the history of in-network 
contracting with plan and provider, the complexity of the case, 
and the education and skill of the physician. All these factors 
are supposed to produce a fair compensation for the doctor.
    Instead, the insurance companies are the ones that produce 
the sole data used in this process without the consideration of 
other pertinent factors that tend to deflate the rates to in-
network providers and narrow the number of doctors in-network.
    We understand that the impact of these policies is causing 
ripple effects through the health insurance market and 
impacting physicians' ability to negotiate fair contracts with 
insurers to be in-network because all contracts are now being 
negotiated under the OPA [sic] ceiling, as plans know that this 
amount is the most they will pay, whether the physician is in 
or out of their network.
    Dr. Bleier, how important is it that IDR Entities are 
permitted the independence to look at all the allowable 
information submitted by a party to support their offer, and 
then make a determination of payment?
    Dr. BLEIER. I think it is extremely important, and that is 
why I think all--my understanding is all related physician 
specialty groups and physicians supported the Texas Medical 
Association's lawsuit against HHS to make sure that all of 
those factors were considered, and undue emphasis wasn't solely 
placed on the QPA when making those determinations.
    Mr. DAVIS. And then let me ask you, what is the impact of 
these policies on the stability of physician practices and, in 
turn, patient access to physician services?
    Dr. BLEIER. Unfortunately, the way the system is currently 
operating, I think it is going to become debilitating if it 
goes on too long. I think certainly I can speak for my group, 
as an independent group that wants to go out into rural 
communities and potentially provide our services in those 
emergency departments--we already have four in those rural 
communities, we are actually looking to potentially expand--I 
think it is debilitating.
    I think we simply will--our reimbursement and revenue will 
be cut to such an extent we will have no recourse, if this 
continues much longer, but to cut expenses. And our expenses 
are provider staffing hours, our providers. So unfortunately, I 
think it will have a harmful effect on our patients.
    Mr. DAVIS. And finally, I understand that patient wait time 
in emergency rooms is getting longer. Does this impact the 
service?
    Dr. BLEIER. Unfortunately, yes, there is an ongoing 
boarding crisis across the country right now due to a number 
of, I believe, workforce issues--is my understanding. But it 
absolutely creates a difficult work environment for my fellow 
colleagues in the emergency department and, more importantly, a 
very difficult situation, I think, for our patients.
    But as always, as emergency physicians, we do the best we 
can, and we are resourceful with the limited resources that we 
do have. So we still try to provide excellent care to every 
patient, no matter what the conditions are.
    Mr. DAVIS. Thank you very much, and I yield back, Mr. 
Chairman.
    Mrs. MILLER [presiding]. Thank you. I now recognize the 
gentleman from Illinois, Mr. LaHood.
    Mr. LaHOOD. Thank you, Chairman. I want to thank our 
witnesses for your valuable testimony here today, and I am 
pleased that this committee put this timely and important 
hearing together today.
    Understanding the cost of health care services in advance 
empowers patients to make informed decisions for their 
families, better manage their health care finances, and 
advocate for fair and reasonable health care costs.
    Like many of my colleagues, the cost of health care is one 
of the top issues that I hear about from my constituents back 
home in central and northwestern Illinois. Enacted in 2020 with 
strong bipartisan support in Congress, the No Surprises Act, 
which we have heard about today, has largely been a success in 
providing certainty for patients when receiving care. Because 
of this committee's bipartisan work and leadership, today 
patients in every state across the country are better protected 
from most surprise medical bills.
    While this committee made great strides towards protecting 
patients from costly and unnecessary out-of-network costs, we 
have unfortunately seen agency officials bypass congressional 
intent on surprise medical billing protections, which 
ultimately harms patients' access to care. In rural counties in 
my district, access and choice for health care services can be 
a significant challenge. Flawed implementation of the No 
Surprises Act has reduced patient access to care, which in--
particularly, has--which, in particular, has affected rural and 
underserved areas.
    As I visit with my rural health care providers, they 
continually stress the fact that IDR process has been virtually 
inaccessible for small practices, given their limited capital 
availability, compared to many large and urban practices. 
Hospitals and health care facilities should be focused on 
delivering needed care and services, not worrying if IDR 
billing process costs outweigh any benefits for patients and 
providers.
    The No Surprises Act was carefully drafted so as to not tip 
the scales in favor of one party over the other, and my hope is 
this committee and the executive branch can work to remedy this 
imbalance.
    My question for Mr. Bobeck and Ms. Thornton, in your 
testimonies you both mentioned the need to look at the IDR 
process and how reforms in this space would better allow 
dispute filing and compliance with the No Surprises Act. Can 
you both expand on what could be done by CMS to improve the 
functionality of IDR process to streamline and to reduce 
burdens on the parties?
    Mr. Bobeck.
    Mr. BOBECK. Congressman, thank you very much for the 
question.
    The first thing that can ultimately be done is regarding 
the batching process. As many of the congressmembers know, 
batching is a process by which different disputes can be put 
together. Right now the process does not follow normally how 
providers and payers bill each other. They usually bill in an 
episode of care. Somebody comes in, there are various codes 
associated with giving that care, and then they will be paid 
upon that. That is not how the batching process works right 
now.
    CMS is currently undergoing the batching process and 
changing those rules. Making those rules more in tune with how 
people bill would be a very good step in the right direction.
    Additionally, one of the biggest things that could be done 
is ultimately the portal itself. With more implementation of 
the portal, making more fields more clearly defined, parties 
can provide better information. And the more information and 
the better information they will provide, you will get a more 
streamlined process that will have decisions happening at a 
much more rapid rate.
    From our perspective, we have run various algorithms on our 
own end, and we can see very clearly that the better the data 
that is put into the system, the better the outcomes that will 
come out. Thank you.
    Mr. LaHOOD. Thank you.
    Ms. Thornton, do you have anything to add on that?
    Ms. THORNTON. I 100 percent agree with whatever--everything 
that he just said. I think technology can really help 
streamline this process.
    Mr. LaHOOD. Thank you. Those are all my questions.
    Thank you, Madam Chair.
    Mrs. MILLER. Thank you. I now recognize the lady from 
California, Ms. Sanchez.
    Ms. SANCHEZ. Gentlelady, please.
    Mrs. MILLER. Sorry, gentlelady.
    Ms. SANCHEZ. Thank you, Ms. Chairman. I appreciate the 
opportunity to have this much-needed discussion on the historic 
bipartisan progress that we made under the leadership of Mr. 
Neal and Mr. Brady in passing the No Surprises Act back in 
2020. And I am incredibly proud of the work that we did to help 
patients struggling with unexpected out-of-pocket costs.
    Since then, Democrats have worked tirelessly to narrow the 
coverage gap for Americans. We passed the Inflation Reduction 
Act and increased ACA subsidies to decrease out-of-pocket costs 
for lower and middle-income working families. And, as a result, 
we now see our nation has the lowest uninsured rate that we 
have had to date.
    And while the No Surprises Act is largely accomplishing its 
goal in protecting patients and consumers from surprise medical 
bills, many Americans are still saddled with high costs and, 
sadly, very confusing provider networks. For those who are 
struggling with high costs, this also means, unfortunately, 
that they must take on medical debt. One in ten residents in 
Los Angeles County, including many of my constituents, are 
burdened with medical debt, and medical debt is one of the 
largest sources of debt in collections, more than credit card 
debt, more than utilities and car loans combined.
    And it is not surprising that Latino, Black, and Native 
American residents are disproportionately burdened by medical 
debt, and many of these folks are insured. It is not that they 
are not insured, they are insured. So, these networks still 
need to deliver on the promises of the No Surprises Act. We 
still have more work to do.
    Now, Ms. Spicer, you mentioned that health insurance plans 
and providers do not automatically hold patients harmless when 
there are billing disputes. How long, on average, does it take 
for you or one of your employees to help consumers resolve a 
billing dispute?
    Ms. SPICER. Thank you for your question. It depends on the 
case. It depends on the capabilities of the consumer.
    Sometimes, if you are going through cancer treatment, you 
can't call me back for a month. So I don't know what your 
notice says and what--how it relates to your bill and your EOB. 
And I can't really help you until you are well enough to 
communicate with me.
    So, you know, and then other cases we can tell from a quick 
call and an intake script, whether or not a bill is a surprise 
bill and what to do about it. So it really just depends on the 
case. But I would say, on average, anywhere from six weeks to 
six months.
    Ms. SANCHEZ. Six weeks to six months. And that is what the 
help of someone who is very familiar with the insurance system. 
Would it be fair to say that consumer assistance programs are 
still under-utilized by many Americans?
    Ms. SPICER. Yes, I think that is fair to say. We get, at 
New York's Health Insurance Consumer Assistance Program--we get 
8 to 10,000 calls a year. We are on the Explanation of Benefits 
and the Adverse Determinations of Commercially Insured 
Consumers, and recently last year added to the Adverse 
Determinations of Medicaid-Managed Care Consumers. So we have 
kind of a broader audience that is--those are state regulations 
that require that notification to consumers. Otherwise, they 
wouldn't know that we existed.
    Ms. SANCHEZ. And so, what happens to the families and 
patients who don't know to seek out the help that a consumer 
assistance program provides?
    Ms. SPICER. They would pay a bill, or they would not be 
able to pay a bill and go into debt.
    I got a client on our help line last week who received a 
bill for an out-of-network lab, but not a corresponding EOB. 
And if you don't have an EOB to explain that your bill was 
denied as out-of-network but could be a surprise bill and 
follow that process, and you are not held harmless by the plan, 
and you are not savvy enough to know, you would pay.
    Ms. SANCHEZ. Thank you. So, often times the people who are 
least in a position to pay end up paying.
    We have also seen provider networks grow narrower over the 
past few years. Mr. Budzinski, have you seen the provider 
network in your community change over the last few years?
    Mr. BUDZINSKI. Yes, Representative. We do see, particularly 
with the advent of the Health Insurance Exchanges, major 
insurance companies in the country have decided that narrow 
networks are an appropriate structure for Health Insurance 
Exchanges. And many of the major insurance companies in this 
country operate narrow networks in the service areas we serve.
    Ms. SANCHEZ. Thank you.
    And Ms. Thornton, how do narrow provider networks impact 
the likelihood of a patient receiving a surprise bill?
    Ms. THORNTON. Thank you for the question. I do think it is 
really important to talk about affordability.
    We all benefit when people can afford their health 
insurance coverage. And to do that, our plans need to provide, 
you know, high-quality networks of providers where they can go 
and get care in a time of need.
    To directly answer your question, all of our plans provide 
provider directories that allow consumers to search. And 
thankfully, the No Surprises Act included new provisions, new 
consumer protections that, in the case that someone receives 
inaccurate information, they are held harmless from that. So 
that was a really important part of the No Surprises Act.
    Ms. SANCHEZ. Thank you.
    I want to thank all our witnesses for their testimony 
today, and I yield back.
    Mrs. MILLER. The gentlelady's time has expired. I now 
recognize the gentleman from Georgia, Dr. Ferguson.
    Sorry, Mr. Estes from Kansas.
    Mr. ESTES. Well, thank you, Madam Chair, and I want to 
thank you, all the witnesses, for joining us today on this very 
important topic.
    Mrs. MILLER. That goes off.
    Mr. ESTES. It wasn't too long ago that the committee passed 
meaningful, bipartisan legislation to address a very real 
problem in the country around surprise medical billing. I am 
sure all of us here have constituents who have been impacted by 
surprise medical bills.
    Erin in my district has told me about a nightmare she faced 
after her husband was in the emergency room in Wichita. They 
have insurance, thought they were doing the right thing by 
going to an in-network hospital, only to find out that one of 
the doctors who saw her husband in the emergency situation was 
out-of-network, causing a massive surprise medical bill.
    This is happening all too often in hospital rooms and 
medical facilities across the country, and Republicans and 
Democrats came together to stop it. The No Surprises Act was 
designed to remove patients from the middle of the surprise 
billing, empowering patients with up-front information for 
scheduled procedures, protect patients when emergency services 
were provided, and create a fair mediation process for 
providers and the insurers.
    This bill was the type of common-sense legislation that 
folks like Erin and her husband needed. An emergency room visit 
or scheduled procedure is stressful enough, but it can be even 
more challenging if it is followed by an unexpected medical 
bill from an out-of-network provider.
    But today's hearing is a reminder of why Americans are so 
frustrated with Washington. The unelected bureaucrats at CMS 
have failed the American people by not complying with the 
language in the bill we passed, and instead creating a dispute 
resolution process that doesn't follow the spirit or 
congressional intent of the law.
    Even though elected lawmakers passed the bipartisan No 
Surprises Act in 2020, the Kansans I represent continue to 
suffer because unelected D.C. pencil-pushers are more concerned 
with keeping the status quo than helping patients. The failure 
in the D.C. swamp has led to fewer medical choices, longer wait 
times, and higher costs for patients, while at the same time 
has failed to deliver the transparency this body sought to 
provide for those seeking medical care. Today we are calling on 
CMS, that is entrenched in putting Washington first, to stop 
slow-walking the implementation process and put patients first.
    Mr. Budzinski, I have heard from many providers in my state 
about the incredible wait times for not only the Independent 
Dispute Resolution, IDR, process, but also for receiving 
payment once the IDR process has been concluded. Can you please 
tell me how many of these IDRs you have gone through, and how 
many that have been paid for successfully?
    Mr. BUDZINSKI. Yes, thank you, Representative. Of our 8,000 
requests for determination at Wellstar, 588 have been resolved: 
288, I believe, are in our favor and, unbelievably, only one-
third of those determinations in our favor have been paid by 
insurance companies. And the deficiency is with some of the 
largest insurance companies in this country.
    Mr. ESTES. If that process or that approach continues 
without some change, what does that mean for your business and, 
more importantly, for the patients that you serve?
    Mr. BUDZINSKI. As mentioned earlier, accounts receivable 
that have never--that are never paid will impact our operations 
in the long run. We are hopeful that there will be enforcement 
of the timelines to remit payments to providers who have been 
successful in getting favorable determinations from the IDREs.
    Mr. ESTES. Well, thank you.
    And Mr. Bobeck, I didn't really have a question for you, 
but I did want to say thank you for raising the comment about 
the IDR website being closed, that you can't add any more IDRs. 
I mean, that is one of the things that we have identified by 
law, this process that should be helping people, and we need to 
make sure that it is highlighted that it is not being done. So 
thank you for bringing that up as part of this hearing.
    I just want to say, you know, the No Surprises Act 
explicitly required that we have an Independent Dispute 
Resolution process that should be concluded in a timely manner, 
and payments should be paid no later than 30 days after the 
final decision. These considerable wait times must be addressed 
to ensure that our providers, especially those in rural areas, 
can keep caring for the patients that need them most. That is 
really what we want to focus on, is how do we make sure we 
provide the right care for the right patients, which I think is 
what all of you are focused on, as well.
    So thank you, and I yield back.
    Mrs. MILLER. Thank you, Mr. Estes. I now recognize the 
gentleman from New York, Mr. Higgins.
    Mr. HIGGINS. Thank you, Madam Chair.
    Surprise billing is a weapon in our decades-long war 
between players in the health care industry over who gets to 
keep the fortunes generated each year from patients. What is at 
stake here? According to the American Medical Association, 
health care spending in the United States in 2021 was $4.3 
trillion, or more than 18 percent of the U.S. economy.
    You know, 30, 40 years ago, most health care providers were 
not-for-profits. Businesses paid premiums. Patients typically 
were confronted with pretty modest co-pays and deductions. 
Those days are over. Health care has become big, big business. 
So hospitals, doctors, and insurers are now in competition for 
the health care dollar.
    And then we have found even more egregious players in all 
of this called private equity firms. The Kaiser Family 
Foundation, an article called ``Sick Profit,'' or, 
``Investigating Private Equity's Takeover of Health Care Across 
Cities and Specialties''--that are highly profitable, private 
equity spent nearly $1 trillion into nearly 8,000 health care 
transactions in the past decade alone.
    Private equities are not health care professionals. They 
are moneymakers. In fact, according to Forbes, to doctors 
private equity firms offer an alternative value proposition 
promising to ease physician dissatisfaction with insurance 
hassles. In exchange, physicians agree to relinquish 
significant control of their practice to non-health care 
professionals.
    Ms. Spicer, you have some thoughts about patient 
protections in this area, but it seems to me that what is 
occurring here is Big Money's takeover of health care, 
compromising the best interests economically and in terms of 
health care of the patient.
    Ms. SPICER. Thank you for your question. Yes, many times 
consumers are left with the balance bill, and they are left 
holding the bag. All of these transactions make it more 
expensive in the end for consumers.
    Mr. HIGGINS. Yes, and the surprise medical billing 
legislation, it really is ineffective in addressing this issue. 
Would you agree?
    Ms. SPICER. I wouldn't say that the--all of the surprise 
billing legislation is ineffective in addressing the issue.
    I would say that if all the different provisions of the No 
Surprises Act were implemented, if price--you know, the 
transparency provisions move forward, patients would be able to 
make more informed decisions regarding the care that they are 
getting and to--and thereby, you know, avoid debt.
    I think that, you know, the arbitration, the piece about 
arbitration and the fees, depending upon the rate that is set, 
it passes additional fees on to consumers. But I believe that 
if the original intent of the law is followed, those--that debt 
would not be passed on to consumers.
    Mr. HIGGINS. Yes, it is undeniable that for a for-profit or 
private equity that has taken over a medical practice: what is 
their objective, and what is the leadership's objective? It is 
to reduce expenses and to amplify profits. The only way that 
you do that is to jack-up co-pays, jack-up deductibles, and 
then, when someone goes to use the insurance they have already 
paid too much for, there is very little underlying insurance.
    And I am just concerned that Federal legislation can't stop 
the trend that has begun in health care, and that is it is a 
$4.3 trillion industry annually in America, 13,000 per capita 
in America. And the profit motive is so strong that I am 
concerned that legislation, while appearing to be helpful in 
the margins, is not addressing the fundamental problem.
    With that I will yield back.
    Mrs. MILLER. Thank you, Mr. Higgins. I now recognize myself 
for five minutes.
    I would like to thank Ms. Chu for sitting in here for the 
ranking member, and I would like to thank all of you for being 
here today, taking your time to discuss with us such an 
important issue.
    Being from southern West Virginia, which is a very rural 
district, my top priority is making sure that my constituents 
have the best access they can to quality health care. In 2020 I 
was absolutely thrilled that the House passed the No Surprises 
Act to help patients all across the nation to deal with their 
medical bills, especially in rural areas, because many patients 
don't have much of a choice about where they receive their 
care. And this policy was a huge win for patient-centered 
health care.
    So you can imagine my surprise when I learned just how 
wrong the implementation of this bill has become. One concern I 
have about the No Surprises Act's implementation is that 
Congress was very clear that ground ambulance services were not 
included in the NSA. However, I understand that some insurers 
are telling customers that ground ambulance services are 
subject to NSA.
    I would like to note that the failure of CMS to issue a 
clarification is creating real problems. Rural ground ambulance 
services are particularly harmed because they are often small 
companies or businesses with very limited resources, and many 
are struggling just to keep their doors open. Reports that some 
insurers are trying to force these rural providers to use the 
time-consuming and expensive process when they aren't even 
subject to it, nor do they have established qualified payment 
amount, this is concerning to me, and I am dismayed that CMS 
hasn't issued the written clarification that would solve this 
confusion. And I hope that this is an issue that we will 
continue to keep an eye upon.
    Dr. Bleier, I would like to thank you for your hard work in 
providing emergency medical care to rural patients. In rural 
areas where access to care is so often limited, it is important 
that patients who are seeking medical treatment--that they can 
do it without the fear of a surprise medical bill.
    One issue that we hear about time and time again is the 
lack of staffing available in our health care workforce. In 
rural areas it is becoming harder and harder to find physicians 
that are willing to practice where their reimbursement rates 
are so much lower. This is due to the coverage mix of their 
patients.
    Can you speak further about how compliance with the NSA, as 
implemented by this Administration thus far, has contributed to 
physician burnout in your workforce, and how this might 
influence physicians looking to start their careers in rural 
areas?
    Dr. BLEIER. Yes, I appreciate the question. I think 
physician burnout is very high among emergency physicians for a 
wide range of reasons, you know, going back toward the COVID 
pandemic. And emergency--I believe it is the highest burnout 
right now out of any of the specialties, based upon some of the 
recent polls that I have seen, unfortunately.
    You know, it is a little bit of a moral hazard right now. 
Our physicians will always want to do right by their patients, 
and we try to do the best we can, and we are used to working 
under very adverse circumstances. But due to a wide variety of 
issues, including workforce-related issues, boarding, workplace 
violence, these are all issues that emergency medicine 
providers and other emergency medicine workers, nurses, et 
cetera have to deal with in the emergency department.
    From the emergency medicine physician and nurse 
practitioner and PA perspective, when our resources for a group 
like ours are fully debilitated--again, we were shocked when we 
find out--found out--when this law was passed, this bipartisan 
piece of legislation, we thought it was a great advancement. We 
did not think we would be affected by it, because we had been 
in-network with all the major payers in our region.
    But then we were kicked out of network, and it is like 
putting salt in a wound, quite frankly, for us. Because not 
only are our providers working as hard as they can to do the 
best they can under very adverse circumstances, but when on top 
of that their reimbursement, their fair market reimbursement is 
cut, it makes it very damaging to them. I think their psyche--I 
think it puts us in a very difficult position.
    And we want to do right by the patients, we want our 
resources not going--having to go to an IDR process. We want 
them to go towards our providers working in the emergency 
department to provide the very best care they can in these 
rural emergency departments or any emergency department we work 
at.
    Mrs. MILLER. Thank you. I yield back my time. I now 
recognize Gentlewoman DelBene from the State of Washington.
    Ms. DelBENE. Thank you, Madam Chair. Thank you to all our 
witnesses for being with us today. I appreciate it.
    Like many of my colleagues on this committee, I was proud 
to pass the No Surprises Act into law to protect Americans from 
unfair surprise medical bills. Prior to this bipartisan 
legislation and similar state laws, including in Washington, 
regular people and families were frequently at risk of being 
hit with devastating surprise medical bills for emergency room 
visits and other procedures that were completely out of the 
patient's control.
    And while we have made great progress, there is definitely 
more to do. In particular, there is a critical gap in our 
consumer protection framework, which is surprise bills for 
ground ambulances. According to Washington State's Office of 
the Insurance Commissioner, the vast majority of surprise 
billing complaints are for ground ambulance services, which 
were exempt from the No Surprises Act.
    So, if someone with private insurance in my state has an 
emergency and calls 911 and gets driven by an ambulance to the 
hospital, they are not only on the hook for the co-pays and 
cost sharing if they haven't met their deductible, but may also 
have to pay a surprise bill of $500 on average. For non-
emergency ground ambulance services, that surprise bill could 
go as high as $1,000.
    And it is not just a problem in my state. The Urban 
Institute's Health Policy Center has identified the lack of 
protection against ground ambulance surprise bills as a major 
issue for consumers across the country. And so, Ms. Spicer and 
Ms. Thornton, how has surprise billing for ground ambulances 
impacted people's willingness to seek care in emergencies and 
other situations?
    Ms. Spicer, you want to start?
    Ms. SPICER. Thank you for your question. In my state, in 
New York, ground ambulances are covered under our surprise 
billing law, and were actually covered under the definition--in 
the definition of emergencies. So many, many insured were 
protected from out-of-network ground ambulance surprise bills 
even before our surprise billing law.
    But we still get a number of calls from consumers who are 
federally insured, who have ground ambulance out-of-network 
bills, and they can't afford them. It is hard for them to 
afford, it is hard for them to understand why their plan isn't 
paying, and it deters them from going to the emergency room and 
getting care when they need to.
    Ms. DelBENE. Ms. Thornton. Thank you.
    Ms. THORNTON. Sure. And first it is important to 
acknowledge that our member health plans want to have a robust 
network of ground ambulance providers in their network, because 
we all know when you least expect it that something that you 
may need to take, you may need to need in an emergency or other 
situation.
    You know, it is important to recognize that Congress did 
not include ground ambulances in the No Surprises Act, but we 
do understand that the regulators are really taking active 
input on that question, and really debating how--what 
recommendations to make along that area. So we are actively 
participating in those discussions, and look forward to next 
steps on that.
    Ms. DelBENE. Do you--do you think that surprise billing for 
ground ambulance should be prevented, and we should do 
something here in Congress on this?
    Ms. THORNTON. You know, we do want to make sure that 
patients are protected and held harmless.
    One of the things that I would caution us in thinking about 
is if the arbitration process is broken, like has been 
discussed during this hearing, I would caution us as throwing 
more, you know, cases at that process. So I think it would 
require first fixing that process before we add more to it.
    Ms. DelBENE. Thank you. We will continue to work with all 
of you as we try to move forward on this.
    Also, Dr. Bleier, as you know well, the widespread use of 
prior authorization delays and discourages medical care for 
millions of Americans that are entitled to care. That is why I 
have led the effort in the House, alongside my colleague, 
Congressman Kelly, and others to modernize and streamline this 
very outdated practice. And we have legislation, Improving 
Seniors Timely Access to Care Act, to increase accountability 
and help Medicare Advantage enrollees get faster care by doing 
crazy things like establishing electronic prior authorization 
process, making sure people are responding to provider requests 
faster and in real time, and requiring plans to report on the 
extent of their prior authorization use and how often they are 
denying requests.
    When we talk about the challenges that providers are 
facing, could you discuss the challenges you and your patients 
have faced due to abuses of prior authorization, as well, and 
why legislation is so important?
    Dr. BLEIER. Yes, we--I haven't dealt necessarily with that 
issue directly from my perspective in the emergency department, 
but I think we have certainly all dealt with it indirectly, 
where patients maybe go to a community provider, they are 
evaluated by that community provider, that community physician 
feels that that patient study is warranted and medically 
necessary, but they are unable to do so. And then the patient 
is referred to the emergency department because they are then 
able to get the very necessary study in the physician's 
perspective.
    Ms. DelBENE. And we talk about doing a good job of helping 
providers and patients, here is another area we need to 
address.
    Thank you, Madam Chair. I yield back.
    Mrs. MILLER. Thank you, Ms. DelBene. I now recognize the 
gentleman from Tennessee, Mr. Kustoff.
    Mr. KUSTOFF. Thank you, Madam Chair, and thank you for the 
witnesses for appearing today.
    I know that a lot of you have talked about the--maybe the 
common experiences that you have had, and the frustrations you 
have had with the whole process.
    I could, Dr. Bleier, with you--and if I can, I tried to 
talk to as many providers as I could about all these issues, 
and one thing that kept coming back was--and you have talked 
about it, Mr. Budzinski, you have talked about it--is you go 
through the process and you prevail, whatever that means, and 
then you have got however long it takes for you to get paid. 
And cash flow is an issue whether you are operating a medical 
practice, or a hospital, or a retail store, or any business.
    So, Dr. Bleier, I am going to turn it around, if I could, 
to you. You know the framework. You know what has been 
implemented. If you could wave a magic wand, what would you do 
to fix it? How would it be fixed?
    Dr. BLEIER. Well, I believe I will be speaking out of my 
turn to some extent, but I would, I guess, hire a lot more 
IDREs, a lot more arbitrators to quickly and efficiently handle 
the backload--backlog of cases. There is a lot of cases in the 
pipeline.
    And then I would also put a lot of resources into 
enforcement. I would want--I would like to see enforcement. I 
think it would be beneficial to see enforcement that the QPA is 
being calculated appropriately--without ghost rates, for 
example, et cetera. Even with the judicial ruling, they sort of 
set the framework stating that that shouldn't occur. But there 
is no enforcement or transparency, currently, as far as I 
understand.
    And then certainly, some enforcement in making sure that 
the arbitrator's rulings are carried out and payments are sent 
to providers and hospitals appropriately. So I would say 
enforcement, transparency are the big things.
    And then to do something to efficiently work through the 
backlog right now in the system.
    Mr. KUSTOFF. I will come back to the backlog in a moment. 
How would you enforce payment?
    Dr. BLEIER. I would imagine there would have to be some 
teeth in it. You know, a small--you know, a $350 non-refundable 
arbitration fee for a group like mine is a lot. That is 
probably not a lot for, you know, very large insurance 
companies, given their size and their net profitability 
quarterly, which is--dwarfs a small group like ours.
    So I don't know what that price point would need to be in 
order to enforce payment and then carrying out what the law 
states they are supposed to do----
    Mr. KUSTOFF. Right.
    Dr. BLEIER [continuing]. But it would need to be 
significant, I would imagine.
    Mr. KUSTOFF. I think in your testimony or in your written 
testimony you talked about--that the majority of your 
submissions are $1,000--under $1,000, I think, is how you 
characterized it.
    Dr. BLEIER. Yes, that is correct. That is my understanding.
    Mr. KUSTOFF. And do you know how many submissions, how many 
claims you have submitted, your practice has submitted?
    Dr. BLEIER. I believe we have submitted about 400 claims 
because it just seemed like, you know, number-one, early on, 
you know, despite what the bipartisan piece of legislation 
stated, the regulations, I believe, stated that the QPA should 
be the primary determinant. We knew we were going to lose those 
cases, so we had those sorts of issues.
    We also had the associated very high fees which excluded 
us, the backlog, the fact that even when we did submit we 
didn't receive payment. So all of those issues prevented us, 
essentially, from accessing the system. We are hoping to moving 
forward, but that has been our experience.
    Mr. KUSTOFF. Thank you, Dr. Bleier.
    Mr. Budzinski, in your written testimony--and I was going 
to ask you about how you would solve it, but you talked about 
how this law disincentivizes health networks. I think the way 
you characterized it was from having robust networks. So if you 
could wave a magic wand, what would you do to resolve issues 
and fix it?
    Mr. BUDZINSKI. Yes, thank you for your question, 
Representative.
    First and foremost, the framework is as follows, as we 
understand it. The courts have found that the administrative 
process has been tilted in payers' favor.
    Number two, we have just discussed today the fact that 70 
percent of the providers are found--the IDREs are finding in 
favor, in favor of providers. So the deck is stacked toward the 
payer in the process, and the providers are still winning 70 
percent of the time.
    Why is that? What is causing this? What is the root cause? 
The root cause, I believe, is that the payers' initial payment 
to providers is being found to be substantially below what is 
necessary.
    So the magic wand is to require administrative processes 
that the initial payment from payers be consistent with the 
historical practice of payment for out-of-network providers. If 
that were the case, I believe these backlogs would disappear. 
That is what I believe.
    Mr. KUSTOFF. Thank you very much. I yield back my time.
    Chairman SMITH [presiding]. Thank you. Mr. Steube is 
recognized.
    Mr. STEUBE. Thank you, Mr. Chairman.
    Earlier this year HHS Secretary Becerra acknowledged before 
this committee that there have been more claims than initially 
estimated, and the arbitration process has been overwhelmed. 
The Centers for Medicare and Medicaid Services have contracted 
with 13 entities to arbitrate cases. All 13 have different 
processes for arbitration, and CMS has not had a uniform or 
concise action in implementing the law. The Department of 
Health and Human Services has been very slow to roll out this 
law, and it is the constitutional obligation of the executive 
branch to carry out what Congress passes.
    Ms. Thornton, I would like to start with you. I would like 
to ask you a few questions about the bureaucratic failures at 
CMS, and maybe help me understand the almost inexcusable 
directives and inability to follow congressional intent with 
how the No Surprises Act has been rolled out. How much of this 
can be cleared up by congressional action, as opposed to CMS 
issuing clearer guidance?
    Ms. THORNTON. Right. Thank you for the question.
    I do think, you know, it is important to recognize that 
the--you all passed the No Surprises Act to make sure that 
coverage was more affordable, and to really make sure that 
patients were held harmless from one perspective, but also we 
didn't do anything to drive up premiums. So I do think it is 
really important, as CMS is putting out guidance and 
regulations, that we are looking at the affordability impact.
    You know, we have weighed in on all of these different 
guidance and regulations. We do stress the importance of 
ensuring a balanced process between providers and health 
insurance plans to make sure that we are not using this process 
a lot. Unfortunately, in how it is rolled out, there certainly 
has been an over-reliance on the use of IDR, 14 times more than 
was initially anticipated, and that has certainly been really 
challenging, from our perspective.
    Mr. STEUBE. Are there reforms that CMS can make today to 
clean up the dispute resolution process?
    Ms. THORNTON. Absolutely. I think it is really important to 
focus on solutions.
    You know, there has been a lot of talk with my co-panelists 
here around payment and challenges with getting paid on time. I 
think by rolling out more robust infrastructure and technology 
to give us a clearer dashboard of all of these various claims 
and where they are in the process would really go a long way to 
mitigate any payment delays that any of the panelists are 
experiencing.
    Mr. STEUBE. Is there a variation across the 13 arbitration 
firms handling the cases and how they process the claims?
    Ms. THORNTON. Absolutely. We have seen a lot of really 
challenging scenarios, you know, making decisions for claims 
that were really Medicare claims and not subject to the No 
Surprises Act, really wide variations in the decisions that are 
coming out--the same provider, the same area, the same service, 
but a drastically different decision coming out. And 
definitely, we would recommend the regulator to do more to 
ensure consistent processes among the different entities.
    Mr. STEUBE. Wouldn't it bring more efficiencies if CMS 
standard [sic] the processes across the board?
    Ms. THORNTON. Absolutely.
    Mr. STEUBE. Are there certain suggestions, other than what 
you just mentioned, that you would suggest?
    Ms. THORNTON. I think greater oversight and review of the 
practices of those entities would be well received from us.
    Mr. STEUBE. Mr. Bobeck, I have got a couple of questions 
for you. What steps, if any, can Congress take to resolve the 
dispute resolution process between the hospitals, doctors, and 
insurers, while at the same time protecting consumers from the 
balance--from balance bills?
    Mr. BOBECK. Congressman, thank you for the question.
    Number one, I believe that Congress continue to see the No 
Surprises Act through. As noted, millions of consumers are not 
getting surprise bills. That is a success story that has 
happened, and that is a universal agreement across the entirety 
of the spectrum.
    When it comes to the payers and the providers, continue to 
put the pressure and the onus on the parties, as well as the 
government to put forth rules that will clearly allow them to 
speak with each other, understand what exactly they are 
disputing. And I assure you those claims will go faster and 
smarter.
    Again, in our group we don't have a backlog. We have never 
had a backlog. Cases go out within the 30 days. And the more 
information the parties can share with each other, the cleaner 
their claims will be and more disputes will go out the door.
    Mr. STEUBE. How accessible is it for you to get questions 
answered by HHS?
    Mr. BOBECK. It is a continuing conversation that we have to 
have with the government upon various aspects of how they would 
like the process to be implemented.
    To be fair, and it has been noted, yes, IDREs do have to 
make decisions based upon the best evidence that they are 
provided. In certain cases there is not a uniform standard that 
is published. But in guidance we are all instructed to move in 
the same way. With that being said, yes, there can be some 
small delineations among the IDREs of how to go about that 
process.
    Mr. STEUBE. And I will just--I have only got a couple of 
seconds left here. Dr. Bleier, does it make sense for HHS to 
charge a $350 administrative fee even to hear disputes that are 
less than that amount of money, especially with x-ray and other 
radiological services?
    Dr. BLEIER. No, it doesn't.
    Mr. STEUBE. Thank you. Thank you all for being here today. 
I yield back.
    Chairman SMITH. Ms. Chu is recognized.
    Ms. CHU. I would like to thank all the witnesses for your 
testimony today on this important issue.
    Prior to the No Surprises Act becoming law, millions of 
patients struggled with financially devastating surprise 
medical bills. As this law continues to be implemented, it is 
important that we build on the progress and continue to protect 
patients from unexpected out-of-pocket costs, while also 
promoting fairness and payment disputes between insurers and 
providers, as the law intended.
    Ms. Spicer, as you highlighted in your testimony, consumer 
assistance programs like CSS New York have played an incredible 
role in helping millions of Americans navigate all kinds of 
health care concerns, from understanding how to use their 
health insurance, resolving medical bills that are often 
confusing and conflicting, appealing health plan decisions, and 
disputing surprise medical bills.
    Now, New York is fortunate in having your organization. 
However, Congress has not appropriated funds for these programs 
since 2010, leaving many states without this resource. Most 
consumers who are eligible for CAP assistance are enrolled in 
employer-sponsored plans. And the majority of these plans are 
federally regulated. But CAPs that operate with no Federal 
funding cannot manage this large scope of work.
    So as patient confusion around health care continues to 
grow, can you talk about the importance of increasing Federal 
funding for Consumer Assistance Programs, and how CSS New York 
and other programs could use this funding to help more patients 
navigate surprise billing?
    Ms. SPICER. Yes, thank you for your question.
    Health insurance generally is incredibly complicated. We 
have all, as insured, gotten a notice that we don't understand, 
an EOB that doesn't make sense in terms of the care that we 
received, a bill that we feel we shouldn't pay for a giant 
package in the mail, or an online login that explains our 
network directory or our summary of benefits, our plan 
contracts that we have no idea what it says and don't even read 
it.
    And currently our state funds our program after we lost 
Federal funding in 2010.
    It is hugely important for people like you and me to get 
help with their health insurance because, unfortunately, in 
America you need a lawyer in order to properly access care 
sometimes and get insurers to pay claims and get providers to 
stop billing you.
    Ms. CHU. So that Federal funding was important. Yes. And 
also----
    Ms. SPICER. Absolutely.
    Ms. CHU [continuing]. You are in a unique position, being 
in New York. I would like to ask about the differences you have 
witnessed in terms of patient experiences in the time following 
the enactment of New York's out-of-network surprise billing law 
in 2014 and then after the enactment of the Federal No 
Surprises Act. What changes have you observed in patient 
dispute volumes, types of billing disputes, and other factors 
between 2014 and now, before the No Surprises Act became law 
and in the years following the law's enactment?
    Ms. SPICER. Thank you for your question.
    After the--before the passage of New York's surprise 
billing law, we saw all sorts of out-of-network--classic out-
of-network billing cases that the NSA now covers, in-network 
hospital, out-of-network radiologists, or out-of-network lab, 
or out-of-network slew of services that were uncovered. After 
our state law those classic cases were covered by the NSA.
    And there were some things missing, including network 
directory misinformation, which was the largest volume of calls 
that we got after we passed our own law in New York State. The 
second largest volume, of course, was federally insured 
consumers who just had no protections.
    And now, since the passage of the NSA, the volume is less, 
but we still have many calls just about understanding what the 
process is and whether there--the consumer--the bill that the 
consumer is getting is a surprise bill, and how to cure, if it 
is.
    And then we still get many calls about ground ambulance for 
federally-insured folks and other kind of follow-up to the ER. 
You are not--if an ER doctor puts a stent in, you are not going 
to get another doctor to take that stent out, so you have to 
incur an out-of-network cost outside of the ER for that. So 
there are some loopholes there.
    Ms. CHU. So there is improvement that is needed. But there 
was some improvement with the No Surprise Act bill.
    Ms. SPICER. Absolutely, huge improvement. And also in 
regards to air ambulance.
    Ms. CHU. Okay, thank you.
    Chairman SMITH. Dr. Murphy is recognized.
    Mr. MURPHY. Thank you, Mr. Chairman, and I want to thank 
the witnesses for showing up today.
    It is really, I think, a very sad state that we passed a 
very, very good law that had a lot of debate internally, 
bipartisan support over here, bicameral support, signed into 
law by a president, and then, when there was a new 
administration that came in, decided--what was a balanced law 
between providers and insurers--to pretty much put everything 
in the insurers' pocket. It is an absolute disgrace.
    And we have met with Secretary Becerra once, two, three 
times, and the answer was it is always in court.
    I absolutely applaud the Texas Medical Society for suing 
against this, because what has happened is, yes, I think we all 
have a consensus agreement that the No Surprise--or that 
surprise billing was an absolute problem. Take it out of the 
hands of the patients, absolute. But when you turn a process in 
which is supposed to be equal and balanced, which was 
absolutely done, and you turn it all over to insurance 
companies, I am not sure what the Administration is trying to 
prove, but this has become an absolute boondoggle for insurance 
companies.
    Mr. Speaker, I would like to ask unanimous consent to enter 
into the record a letter from Blue Cross Blue Shield of North 
Carolina to a physician practice stating that the interim final 
rules--and this was probably two days after the interim rules 
came out--provide enough clarity to warrant a significant 
reduction in your contracted rate with Blue Cross Blue Shield.
    In some instances, insurers, the next day after the rule 
was proposed, cut fees 40 percent. Guys, we all know that 
medicine is a business, sad enough, but there is no stability 
in that when the insurance company is absolutely raping 
(reaping?) profits off of the backs of those who provide the 
care.
    So with all--unanimous consent I ask that this be done.
    Chairman SMITH. Without objection, so ordered.
    [The information follows:]
 
    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. MURPHY. There was no teeth in the legislation, sadly 
enough. Thirty-day rules once things were adjudicated. We are 
going to get to some teeth in this, and the people who are 
holding out the money may not like it, and I invite them to 
come in my office and help us craft legislation.
    Dr. Bleier, thank you for being in here. The statutory 
language was very, very clear. The Administration chose not to 
use it, and only to use the QPA as the primary consideration in 
the IDR process, which insurance companies have deflated on the 
dollar.
    And by the way, they are not hurting. United, 20 billion--
with a B--in profits, while we have practices that are not 
being paid for months, for months after they have been 
adjudicated.
    So, Dr. Bleier, what has your experience been with the QPAs 
offered by the insurance companies?
    Dr. BLEIER. Sometimes we don't know if we are being offered 
a QPA. It is often times not listed on the initial payment. But 
the QPAs can vary tremendously, and sometimes they don't really 
make a whole lot of sense with the marketplace.
    So, you know, our understanding in speaking to colleagues, 
as well, is these QPAs are cited, and a lot of smaller groups--
and our own, for example--have even less bandwidth to deal with 
that decrease in reimbursement, given their staffing models, 
and often times are forced to come out of network. They are 
kicked out of network due to a cited QPA that may or may not be 
correctly calculated with no transparency to verify, and they 
are forced back in-network at a substantially lower contracted 
rate. And I think that has been a real issue for a lot of 
groups, from what I hear.
    Mr. MURPHY. It is a destruction of medicine, and I lay that 
flat on the hands of our insurance companies.
    You know, we have seen this with PBMs, the absolute 
extortion that is going on with them. And it is all vertical 
integration charged by our insurance companies.
    According to a survey, 50,000 doctors, those who take care 
of patients, said that 100 percent of providers have been 
threatened with contract termination. What a way to treat your 
clients. What a way to treat your clients. ``We are cutting 
your prices, those of you who take care of the patients. We are 
cutting your prices so our CEOs can earn millions and millions 
of dollars.''
    On average, 81 percent of providers had an average of nine 
in-network--in-network--contracts terminated by payers, things 
that were going fine until, all of a sudden, insurance 
companies decided, well, we can take advantage of this. Payment 
cuts up to 52 percent. Nearly 60 percent of payments won in 
arbitration were not paid within the 30-day termination.
    And I want to ask Ms. Sailer there, you said that it didn't 
fit--holding back money did not fit your business model. Can 
you explain what you mean by that?
    Ms. THORNTON. Ms. Thornton? You meant me? Sorry.
    Mr. MURPHY. Yes, I am sorry. Yes, yes, yes, yes.
    Ms. THORNTON. Sure. You know, we really depend on having a 
robust network of high-quality insurers. An employer is not 
going to want to buy coverage that doesn't have a robust 
network. So we need to have a collegial relationship with 
providers.
    So I think, with the goal of bringing more providers in-
network, it is not in our best interest to withhold payments. 
Because eventually----
    Mr. MURPHY. Yes, well, you just heard Dr. Bleier, where 
basically people get bullied, kicked out of network to come in-
network at a much lower cost.
    And you know, last I checked, patients' premiums have not 
gone down, have not gone down. They have skyrocketed. And 
insurance companies' profits have absolutely skyrocketed. The 
folks in the middle are what is destroying American medicine. 
The doctor-patient no longer--taking care of the patient, it is 
the folks in the middle who are absolutely, absolutely 
extorting money off of the American patient.
    I will just say this, and I will close. I am going to work 
on proposing legislation. Thirty days is fine, but when we put 
no teeth in that bill, that is going to add one percent 
compounded daily for insurance--to insurance companies who do 
not pay their claims on time. And I am happy to work with you 
all, but this is ridiculous. When you all don't pay claims 
eight months, nine months out, are you just waiting for the 
practices to go bankrupt? Because that is what is happening. I 
am happy to work with you all, but I am moving forward with 
this. Enough is enough is enough.
    Thank you, Mr. Chairman. I will yield back.
    Chairman SMITH. Ms. Tenney is recognized.
    Ms. TENNEY. Thank you, Mr. Chairman and Ranking Member, and 
thank you to the witnesses for your work and for the insight 
that we have received here today.
    It is hard to believe that just under three years ago we 
came together in a bipartisan way, bicameral way to come up 
with a No Surprises Act, groundbreaking legislation. And this 
legislation, as we all know, is intended to finally hold 
patients harmless for surprise medical bills and encourage 
payers and providers to come up to create larger networks.
    Since then, as we--you have heard pointed out by many, we 
have had unelected bureaucrats really fail to comply with the 
language intent of the law, and this has diminished the 
achievement of the No Surprises Act.
    And I just wanted to come up with a couple of--I have a 
couple of different things I wanted to bring, just some 
examples. And I wanted to cite one first, and then I want to 
get into questions to each one of the witnesses.
    So my first example is in May of this year an air ambulance 
provider transported two twin infants from the same 
transferring hospital to the same receiving hospital. Each 
infant required its own ambulance, and each was delivered 
safely to the receiving hospital. I am told the same insurer 
provided the health insurance for each of these critically ill 
twin infants. The situation was identical: two transports of 
sibling infants with the same origin and the same destination 
and the same ambulance service. Yet the insurer applied two 
drastically different qualifying payment amounts, QPAs. One QPA 
was nearly $13,000 more than the other for the base rate, and 
greater than $100 more per mile traveled.
    I am not sure who to direct this to, but I am thinking 
maybe, Mr. Bobeck, you could explain to us. How is this 
possible, that we have this completely identical circumstance 
and the QPAs would be completely--would be--how can this be 
appropriate and compliant with our regulations under law?
    And maybe just give us a quick explanation, because I want 
to ask Dr. Bleier about that, as well.
    Mr. BOBECK. Thank you for the question. Respectfully, under 
the rules we are not allowed to even determine the QPA. We are 
only allowed to use the QPAs as given to us.
    The IDRE's job is then to look at other evidence that would 
support whether or not--that the payment made in this case was 
correct or not. So respectfully, I would yield to the other 
parties on this, as we can only make decisions based upon the 
evidence that is presented to us in a particular case. Thank 
you.
    Ms. TENNEY. Thank you.
    Dr. Bleier, how does this happen with this? How can we--how 
do we fix this?
    Dr. BLEIER. I----
    Ms. TENNEY. It is a real injustice to our--to the people 
that we are trying to serve.
    Dr. BLEIER. Yes, it is a horrible set of circumstances. I 
am sorry to hear. I have no explanation, because I also have no 
transparency, you know, no view into how that QPA is 
calculated. It is not----
    Ms. TENNEY. How would we--maybe we could just pass this on.
    How would we solve this problem, Ms. Spicer? I am going to 
ask you the next question. Similar issues with dispute 
resolution, but this is something that is really maybe a 
failure on the part of our--of CMS and our enforcement. And as 
Dr. Murphy alluded to and others, there is no teeth in this 
legislation to make sure this doesn't happen.
    I don't know if you would have a----
    Ms. SPICER. It is--I would also defer to others on the 
panel. I really--I am not privy to what information is 
submitted with that--with those claims to come up with two 
separate----
    Ms. TENNEY. Let me--in reference--I have found it 
interesting that you mentioned in your recent discussion with 
one of my colleagues that you need a lawyer, basically, to deal 
with some of these issues. And I recently had an organization 
come to me with complaints that, despite the No Surprises Act, 
some insurance companies are continuing to apply entire 
balances to the patient's responsibility.
    In one example, a family was billed for the full amount 
after the insurance company denied their providers--again, an 
infant situation, a neonatal critical care claim for their 
underweight newborn. I mean, how often do we see these illegal 
billing practices like this?
    And if so, are you seeing any enforcement of it--referring 
again to there is no teeth in this, we need lawyers. I mean, I 
don't know if you----
    Ms. SPICER. Yes. So in my experience--thank you for your 
question. In my experience, the bill comes directly from the 
provider to the family. The family doesn't understand why. And 
so then what I do in my practice is to get the--put the plan on 
the hook, make them aware that this bill is something that the 
consumer should be held harmless for, and that it falls under 
the No Surprises Act.
    But if the consumer doesn't understand that there is even a 
protection in existence that they can take advantage of, they 
might pay that bill or go into debt for that bill. And then it 
is about really fighting with the insurer to make sure that the 
consumer is held harmless, filing grievances and complaints 
with the regulator.
    Ms. TENNEY. Thank you.
    I don't know if I have time for another question, but Dr. 
Bleier, in your testimony you outlined how some health 
insurances are using the No Surprises Act to finally--
financially squeeze providers and, in some cases, drop them 
entirely and instead depend on the No Surprises Act IDR 
process. This leaves some patients with an insurance plan that 
does not have a network provider in their area, the opposite of 
the law's intended result.
    And I believe I am out of time. You could either answer or 
maybe answer us online in another forum, it is up to the 
chairman. Just--I just want to--how does the lack of this local 
network, you know----
    Chairman SMITH. Respond briefly.
    Ms. TENNEY. Yes.
    Dr. BLEIER. Ironically, when there is not enough resources 
in the community because of a narrow network, those patients 
end up coming to the emergency department. We take care of 
them. We take care of them no matter what. It is our duty, our 
Hippocratic Oath. It is part of EMTALA. So it increases--it 
drives the patients to the ED.
    Ms. TENNEY. Thank you. My time is expired. I yield back. 
Thanks so much to the witnesses.
    Chairman SMITH. Ms. Moore is recognized.
    Ms. MOORE of Wisconsin. Thank you so much, Mr. Chairman, 
and I want to thank the witnesses for their patience.
    I had a couple of questions that I wanted to ask. One of 
the things that really wasn't clear to me--and maybe Ms. 
Spicer, Mr. Budzinski, Mr. Bobeck, any of you might be able to 
answer--is there a particular pattern which will characterize 
those sort of claims that are disputed that fall through the 
dispute resolution process?
    You know, all of you talk about the thousands and ten of 
thousands of transactions that come through. Is there a 
particular medical practice? Is it OB-GYN? Is it baby care, 
elder care? Is there a certain type of expenditure which might 
inform some sort of repair of the dispute resolution process, 
where you could start to say, ``This is where it seems to be 
failing the most in terms of denials?''
    Uh-oh. Wrong question, huh?
    Ms. SPICER. Thank you for your question. I can say I 
haven't seen a pattern in my practice, but we are--our state 
doesn't use the same process for--before the NSA we had this 
baseball arbitration process, and it was all kinds of claims.
    And to echo what members of the panel had said, what I 
would do in these sorts of scenarios was try to figure out 
first if it was even worth it for the patient to do IDR. 
Because if the patient was engaging in IDR, they would have to 
pay the fee unless they won. And so was--you know, there is 
kind of these baseline inquiries. Are you eligible? Does your 
bill count towards the surprise billing law? And then does it 
even make sense for you to file?
    But I didn't necessarily--I would--people would get to me 
when they had really big bills, like surgery, for example. That 
is when you engage with a lawyer.
    Mr. BOBECK. Congresswoman, thank you for the question. One 
pattern that we have noticed clear throughout the process is 
the more information that the parties have and that they share, 
the better the process becomes.
    In the beginning of this process, when people submitted 
claims, only about 50 percent actually became eligible. That 
number for us right now is closer to 87 percent of these cases 
are eligible. And the ones that are not, that are determined 
ineligible, that is mainly because of information they did not 
have. If they are trying to put various claims together and 
then they miss a certain key piece of information with it, that 
claim will get kicked out. If they miss certain timelines that 
they were not aware of, that case will get kicked out.
    And as I also mentioned before, if they try to submit a 
claim that is Medicare, something related to the VA or 
Medicaid, those cases also would get kicked out.
    These are cases of misunderstanding of the process. People 
are getting better, and it is the one salient point we have 
seen through this process. The more people share and understand 
that information, the more seamless the process goes, and the 
better it works for everybody.
    Ms. MOORE of Wisconsin. So maybe this is to Mr. Bobeck or 
someone else. You have talked about--and I think you, Ms. 
Spicer, talked about in New York that you would have as many as 
a million of these claims come through in a a month's or a 
week's time. Is there a plan, once the portal is open again, to 
do the huge backlog that will be there?
    What do you anticipate in terms of the workload and the 
workforce after the portal is reopened?
    Mr. BOBECK. Congressman, from our perspective--and the 
providers can certainly speak for themselves, and the payers, 
on how they initiate claims--from our perspective, we have been 
on hold now since August 3, 2023. We have a large staff that is 
standing ready. They are training, they are going to do 
everything possible to be ready, because we do know that there 
is going to be a large tsunami of cases that will be coming 
through that door.
    For our staff, we have also made increased investments in 
our technology on our own case management systems to more 
seamlessly get through these cases whereby we will not have 
that backlog, cases will move forward. But we also have to move 
lockstep with the payers and providers because they are allowed 
10 business days, or 2 weeks, to provide us their payments, to 
use the system, and at the same time provide us their offers. 
They are also going to need to be our partners in this in 
making sure we get that information seamlessly.
    But from our perspective, we have people ready, waiting, 
and looking forward to starting this process sooner, because 
that backlog of new cases will only get worse the more this 
holds out. Thank you.
    Ms. MOORE of Wisconsin. Anybody else with any? I got nine 
whole seconds left.
    Mr. Chairman, I yield back.
    Chairman SMITH. Mrs. Fischbach is recognized.
    Mrs. FISCHBACH. Thank you, Mr. Chair.
    And I think Mr. Kustoff asked maybe the doctor a little bit 
about, you know, if there is something Congress should do to 
help enforce payments once they are settled. But I wanted to 
ask Mr. Budzinski--I am sorry, I pronounce German names, but 
not--and Mr. Bobeck about if they have some input on that.
    Mr. BUDZINSKI. Yes, thank you. It is Budzinski, and I 
appreciate your challenge.
    With respect to what is the one root cause that is causing 
all these disputes, I think there is no question about it. The 
initial payment from the insurer to the provider is being set 
by the insurer, and it is being proven that the insurer is 
underpaying providers under the Act. And until that issue is 
resolved in some way, shape, or form, the process is going to 
continue to unfold, I believe, in a similar fashion.
    Insurers no longer have a need to contract with emergency 
departments of hospitals or emergency physician groups because 
they can underpay, and it gets into this process, and then the 
disputes blossom. And now we have backlogs like this.
    So the initial payment should be established with a minimum 
floor. That minimum floor should be consistent with out-of-
network historical practices for payment or, frankly, insurance 
companies often have a secondary contract. They have a 
secondary contract with a third party that providers often do, 
as well. These are out-of-network service arrangements with 
discounts to providers. Insurance companies are ignoring those 
contracts, and they are simply paying the initial payment 
amount under the Act without regard to their access to another 
contract.
    Mrs. FISCHBACH. Thank you very much.
    Mr. Bobeck, do you have some input on that?
    Mr. BOBECK. One thing we continue to repeat throughout this 
is that, ultimately, the more the parties have experience and 
expertise in submitting these claims, the better the process 
becomes.
    We don't believe the answer is having more IDREs, because, 
ultimately, that would be bringing in more groups that don't 
understand the system and how the rules are put forth. You need 
groups who have the understanding and expertise to move forward 
and get these claims paid and adjudicated in a timely manner. 
That is where all of our people over the last year have spent 
their time.
    We are referees. We do not come up with the rules, but we 
are the ones to enforce the rules, and that is ultimately the 
process that we move forward on best. And we have noticed when 
people understand the rules, it makes it a lot easier for us to 
make the decision. Thank you.
    Mrs. FISCHBACH. Do you think there is room for more 
enforcement? Should Congress be acting on something?
    Mr. BOBECK. One of the pleasures of being the referees is 
we are not allowed to comment upon the rules. [Laughter.]
    Mr. BOBECK. But we may not be able to define the strike 
zone, but I assure you we will call the balls and strikes as 
you give it to us. Thank you.
    Mrs. FISCHBACH. Thank you very much, and you are very 
diplomatic.
    Voice. I can explain the sports references.
    Mrs. FISCHBACH. Oh, he--my good friend is going to explain 
the sports references to me.
    But--and maybe what I should do is ask if there is anyone 
else on the panel who would like to comment on that.
    And I don't see any. Oh, here we go. Ms. Thornton.
    Ms. THORNTON. I just wanted to respond to the question 
that--or the comment that we are making artificially low 
payments as our QPA. You know, the regulations have, and the--
your legislation had pages and pages of very detailed 
information that we have to abide by when we calculate those 
QPAs, which are based on actual contracts between providers and 
plans. So I just wanted to emphasize that we are following 
those regulations when we are calculating that, and we are 
following it by the line.
    Mrs. FISCHBACH. Okay, thank you.
    Since I don't see any other volunteers, I will yield back, 
Mr. Chair.
    Chairman SMITH. Mr. Fitzpatrick is recognized.
    Mr. FITZPATRICK. Thank you, Chairman. Thank you for holding 
this hearing.
    The No Surprises Act was signed into law, as we all know, 
back on December 27, 2020 to protect patients against surprise 
medical billing. However, the law has not been fully and 
correctly implemented in the way that this Congress has 
intended it to be. And as a result, patients are hurting in my 
district and districts across America.
    Emergency departments' wait times have more than doubled 
since this law's passage in 2020. I personally have many 
hospitals in my district that have reached out to our office 
about the influx of people and increased wait times in their 
emergency departments, resulting in overworked hospital staff 
and patients, literally, being left in hallways.
    Studies have suggested that 20 percent of emergency 
department visits and 10 percent of elective inpatient care 
stays involved at least one out-of-network provider.
    I want to thank our witnesses for being here today to 
provide us with your firsthand knowledge and your experiences 
on how this law was implemented and is being carried out.
    First to you, Ms. Spicer, the No Surprises Act, obviously, 
was intended to give patients peace of mind that they would not 
receive surprise medical bills weeks or months after what they 
thought was a covered in-network service. Due to your 
interfacing with patients every day, can you speak to what has 
changed for patients since the enactment of the law, and what 
outstanding concerns you continue to hear from patients today?
    Ms. SPICER. Yes, thank you for your question.
    What has changed for patients? They--obviously, in our 
state, in New York, we had a surprise billing law before the 
NSA. So what--I see the change is that now federally-regulated 
consumers are protected from surprise and emergency service 
bills.
    What is outstanding for consumers is--which are complaints 
that I normally get, are grounds ambulance, post-ER visits to 
out-of-network doctors who provided the ER service.
    And one of the things that we do most is just to counsel 
people on what the law means for them, and how it can help 
them, and how to engage in the process. When a mistake is made 
and they are not held harmless, or when they receive a bill, 
usually those two things go hand in hand.
    Mr. FITZPATRICK. Mr. Budzinski, what is your perspective, 
from the hospital standpoint, your concerns about 
implementation, and what are some of the solutions you think 
would address that?
    Mr. BUDZINSKI. Thank you, Representative. I need to ask you 
if you want the whole list, or just the top 10.
    Mr. FITZPATRICK. You can start with the top several. How is 
that?
    Mr. BUDZINSKI. Very good.
    Number one, as I said several times today, the reason there 
are disputes is because the insurance company is in charge of 
making the initial payment amount to providers. There is no 
regulation that currently specifies what that amount needs to 
be. There is confusion about that in some of the administrative 
rules that have come out and that have been addressed through 
other processes where the QPA might be the correct initial 
payment amount, but there is no--it was not the intent of 
Congress to establish that.
    But unfortunately, we believe that the insurance companies 
are now driving a big truck through that loophole and are 
establishing initial payment rates that are very low, creating 
disputes and that what we have heard today is that, when the 
dispute is listened to by the independent person, the 
independent entity, 70 percent of the time the providers are 
right that they were under-paid. And this is when the deck has 
been stacked against providers in the administrative rules.
    So that is number one: initial payment amounts are being 
set by an organization whose benefit is to set them as low as 
possible. There needs to be a minimum established amount 
consistent with what out-of-network payment rates used to be 
prior to the legislation or, at a bare minimum, insurance 
companies should be required to access all their contractual 
agreements for specified discounts, and not ignore those 
contracts.
    In addition to that batching was mentioned earlier. 
Batching needs to be revised, there is no question about that, 
and the bundling of services. Hospitals in particular are 
typically provide--paid on bundled arrangements. In an 
inpatient setting, that is what is called a diagnosis-related 
group case rate. Most of the time, in outpatient ER settings, 
those are called ER case rates. In addition to that, 
observation care that sometimes follows up on emergency care is 
often reimbursed on a case rate. We believe that the bundling 
of those types of things, consistent with how hospitals are 
typically paid, is the right answer, as opposed to every line 
on a bill having to be adjudicated through the process.
    By the way, what that does, from a provider perspective, if 
we can--if we send in one dispute for an ER service, an ER 
visit, that is one administrative fee. If we have to go through 
four or five or six CPT codes on an ER bill, each one of them 
become, in effect, an administrative dispute with payment.
    So batching administrative fee refinement, we believe that 
the loser should pay all administrative fees, quite frankly.
    Those are just the top few.
    Mr. FITZPATRICK. Thank you, Mr. Budzinski.
    Ms. Thornton, I was going to ask you about the insurance 
perspective, but my time is over-expired.
    So Mr. Chairman, I yield back. We will take that for the 
record, that question. Thank you.
    Chairman SMITH. Thank you. Mr. Beyer is recognized.
    Mr. BEYER. Thank you, Mr. Chairman. Mr. Chairman, Ranking 
Member Neal, thank you for holding this hearing. Incredibly 
essential.
    Mr. Budzinski, you just repeated something that was in Ms. 
Thornton's testimony about 71 percent of the disputes that 
reached determination favored the health care providers in the 
area and suppliers. But you have also said that the law was 
never intended to pick winners and losers, and that the health 
insurance companies are winning overwhelmingly. Can you explain 
the arbitrariness of the process, and how we can make it less 
arbitrary?
    Mr. BUDZINSKI. Yes, thank you, Congressman.
    I am going to come back to the law was never intended to 
pick winners and losers. But inside the framework the initial 
payments paid by insurance companies are unregulated, 
unspecified. And that process has created a situation where ER 
physician groups, emergency rooms of hospitals are being 
underpaid initially. And through that process, it only leads to 
dispute. And so this----
    Mr. BEYER. So let me follow up on that because Ms. 
Thornton, again, said thatthey estimated 17,000 claims and said 
they had 334,000. Are you suggesting that the insurance 
companies, by intentionally under-paying, are creating an IDR 
process? You know, creating the surprise billing complaint 
appeal in the first place?
    Mr. BUDZINSKI. That is the belief of our organization. Yes, 
sir.
    Mr. BEYER. Okay. Dr. Bleier, again, leveraging off Ms. 
Thornton's testimony, she pointed out that there is only a 
handful of companies, a handful of states that are filing all 
these claims. You know, 60 percent of the claims from 5 states. 
All the numbers are in her testimony. How do you respond to 
that, that this is not just a handful of emergency room 
practices that have figured out how to game the system?
    Dr. BLEIER. It is hard for me to say what the intent of 
anyone else's business is. I can tell you from our perspective, 
and I suspect by extension a lot of other independent ER groups 
as well, emergency medicine groups out there, I think the 
number of arbitration cases--I believe you cited roughly over 
300,000----
    Mr. BEYER. Yes.
    Dr. BLEIER [continuing]. Would be far, far higher if we 
felt that the arbitration process was working more efficiently.
    We have only submitted 400 claims, and it is largely 
because the process hasn't worked up until now the way we would 
like. And yet we have, you know, institutional damage, so to 
speak, because the loss of revenue that we have experienced 
because of those under-payments up front, we can't get that 
back. There is no process. Unfortunately, with the Texas 
Medical Association lawsuit rulings, they didn't allow for us 
to submit claims, for example, at lower IDR fees going back to 
the beginning of this year. That was not part of the ruling.
    So--but I can't speak to why other groups are submitting 
claims to the--you know, through the arbitration process.
    Mr. BEYER. Okay.
    Dr. BLEIER. But I can tell you our--that has been our 
experience.
    Mr. BEYER. Yes. Mr. Budzinski, Mr. Bobeck mentioned that 
all they do is apply the QPA. They have nothing to do with it. 
You complain in your testimony about the cloak of secrecy that 
QPA has. Where does the QPA come from, and how transparent 
should it be?
    Mr. BUDZINSKI. Yes, so there is a couple of things.
    First of all, we actually have had a number of our requests 
for determinations with Mr. Bobeck's company. And let me just 
say for the record their organization is one of the most 
transparent and engaged IDR Entities that we have come in 
contact with. So, from our perspective, we understand their 
role as a referee, as an arbiter of the facts.
    With respect to the QPA, the QPA is there, I believe, in 
the legislation to protect the consumer. The QPA was not 
established as the correct payment rate for a provider.
    Now, I will tell you we don't really understand how QPAs 
are calculated, nor do we ever receive calculations of what 
QPAs are. But relative to payment to providers, it has not been 
established that a QPA is the correct payment for providers. 
And in fact, we believe in most situations that is not the 
correct payment to providers, and our determination requests 
reflect that.
    Mr. BEYER. Okay, thank you.
    Mr. Chair, I yield back.
    Chairman SMITH. Mr. Moore is recognized.
    Mr. MOORE of Utah. Thank you, Chairman, and I would like to 
thank the chairman and the ranking member for holding this 
hearing today.
    We--let's take a quick moment of pause to just recognize 
what we are doing. We passed something. It has created some 
good for many patients, and we are now reflecting on it. We are 
identifying the challenges of the implementation of it, and we 
are trying to make improvements on it. Any time you give me a 
chance to do that, I will be ready to do whatever work is 
necessary. So thanks for moving the ball forward on this, and 
for having us be able to discuss it today.
    I am going to talk a little bit most mostly about the 
Independent Dispute Resolution, so the IDR process, because 
this implementation of this has not been without its 
challenges, and there has been periodic pauses from this IDR 
process, and it required that several regulations be rewritten 
as agency officials strayed from congressional intent in 
implementing the law.
    So today I would like to focus on how this ever-changing 
regulatory landscape creates a lack of clarity for parties 
resolving claims in the IDR process. And so I would love to 
hear from the witnesses on this particular issue, how has it 
affected your operations.
    Mr. Bobeck, as you note in your testimony, over the last 
two years, as HHS, Treasury, and Labor have implemented 
regulations for the No Surprises Act, the IDR process has 
periodically been suspended. This prevents new cases from being 
initiated through the Federal IDR portal, and prevents IDR 
entities from adjudicating disputes between providers and 
health plans. Can you speak to the operational challenges that 
the--or stop-and-go implementation of this law has had, 
particularly on IDR entities?
    Mr. BOBECK. Congressman, thank you very much for the 
question.
    From the IDRE perspective, the biggest thing that happens 
with the start-and-stop nature of the process is essentially 
that you need to be able to staff up for a process that you are 
never quite sure when it is going to begin again and then also 
have a staff that is ready to handle a tsunami surge of cases 
when it starts back up again.
    So the biggest thing we have to look for in all of our 
staff is, are you prepared for flexibility? And this process is 
only going on for one year. So, if you were to look for experts 
in the IDRE reprocess over one year, you will not find them.
    Mr. MOORE of Utah. Right.
    Mr. BOBECK. So the people that we have on staff, we need to 
maintain them, even if they don't have anything to do. We are 
maintaining them for their expertise and their knowledge. That 
does create costs, obviously, for the IDREs as we move forward.
    But as noted, again, this process is still in its infancy. 
It is moving forward. We have seen the benefits of cases moving 
through the system, payment determinations being made, and we 
know that it is a great responsibility for our job to make sure 
that all the parties, payers, and providers can have their job 
done to help consumers. So we are ready to stand by, and 
whatever challenges we face we feel are much smaller compared 
to what the providers and the payers have to work through, and 
then their patients.
    Mr. MOORE of Utah. Backlogs. Can you speak to--a little bit 
to the backlogs in particular?
    You know, you have generally addressed it, you have talked 
about a year timeline only. But specifically backlogs, how has 
complying with this sort of changing regulatory landscape 
affected that?
    Mr. BOBECK. When it comes to the backlogs right now, when 
the parties ultimately are going to start submitting all their 
cases again, the timeline is still--for us, is still going to 
be clear. The moment that we receive a case, we only have 30 
business days to make an ultimate decision on it. When you have 
an increased number of cases, it does put more impetus on 
having a staff that is cost effective and streamlined, that 
they will be able to handle that.
    And again, we can only speak for ourselves. Yes, there are 
other--12 other IDREs within this process, and ultimately some 
of them are working through some of their older cases that they 
have. But with that being said, for us the only thing you can 
do is continually have a staff that is ready to move through 
those cases because, for us, timelines are non-negotiable; you 
have to do them.
    Mr. MOORE of Utah. Dr. Bleier--and I would welcome comments 
from Mr. Budzinski, as well--I have heard that small and 
independent practices in Utah--I represent Utah--have 
negatively impacted--they have been negatively impacted by the 
IDR process, including from the dispute resolution backlog, as 
I mentioned, and the 600 percent increase in IDR fees.
    Well, these fees--this fee increase was reversed. Could you 
speak to the operational challenges of this stop-and-go 
implementation on provider practices as well as what financial 
impact the IDR backlog has on providers?
    Dr. BLEIER. For a relatively small group like ours, it 
really cripples our operations to a significant extent. You 
know, we don't have the bandwidth or capacity to--you know, 
when we are receiving 70 percent less than our prior 
longstanding in-network contracted rates, to submit a payment 
for $350, $350, let alone $50, right?
    And in addition to that, we have been effectively excluded 
from the IDR process due to all of the things that we have 
discussed today, right?
    The--initially, the way that the QPA was given unfair 
weighting, the backlog, the fact that even when we do submit 
and win a case we are not reimbursed, so that really affects 
our ability to provide the resources that we want and towards 
effective provider and patient care at the bedside--I should 
say patient care at the bedside by our providers.
    Mr. MOORE of Utah. Any final comments? Maybe even has it 
affected rural patients?
    Dr. BLEIER. There is no question that when resources are 
reduced, it is going to affect the capability of providers to 
provide care in the communities they serve.
    Mr. MOORE of Utah. Thank you. Thank you all. I appreciate 
it.
    Chairman SMITH. Ms. Van Duyne is recognized.
    Ms. VAN DUYNE. Thank you very much, Mr. Chairman, and thank 
you to our witnesses for coming to today's hearing.
    In August, I was able to gather with health care leaders 
from across Texas. And during this meeting I heard over and 
over how unelected bureaucrats are failing to comply with the 
No Surprises Act. And while this is not surprising, and 
frustrating for everyone involved, it is the patients stuck in 
the middle that are hurt the most.
    And I am glad to see that we are holding this hearing, with 
my state leading the most amount of disputes, and in Q4 of 
2020, with a total of 25,277 disputes according to CMS reports, 
further adding to the nearly 250,000 unresolved payment 
disputes that are currently clogging the IDR backlog.
    And, while I am also glad to see that my state's medical 
association currently challenging in court--and I do want to 
associate myself with my colleague, doctor and congressman Greg 
Murphy, in his comments lauding TMS--it is--based on these 
decisions, it is apparent that the CMS bureaucrats have elected 
to go around the intent of Congress and make unilateral 
decisions on what they think would be best, causing patients to 
lose care and trust in their providers.
    Every day that passes with the NSA and IDR portal that 
remains closed, it pushes medical practices across America 
closer and closer to insolvency. If the tri-departments keep 
the portal closed for an extended period, potentially up to six 
months, the consequences could be catastrophic. And such a 
prolonged exposure could disrupt emergency medical services 
disproportionately in the State of Texas, my state, putting 
patients at risk and further straining the health care system.
    And it is not just this committee that is dealing with 
this. We are looking at CMS in--changing its intent, hurting a 
number of private practices, small group practices, increasing 
costs, decreasing quality of care. This is a problem, and we 
need to figure out--there is a lot of solutions to it. Getting 
this Administration to actually put forward those solutions and 
getting CMS to actually do its job is another challenge.
    But Mr. Bobeck, I really appreciate your comments dealing 
with the IDR and some of the problems that they are facing 
there. But, in your testimony, you talked about batching and 
how that led to roughly 40,000 cases deemed ineligible due to 
current batching rules. In your opinion, should CMS consider 
revising the batching criteria to be more closely aligned with 
what Congress intended?
    Mr. BOBECK. Congresswoman, thank you for the question. On 
particular with regards to batching, it doesn't totally 
represent all the 40 cases--40,000 cases ineligible, but does 
represent a substantial portion.
    The feedback that we provided CMS ultimately when it comes 
to episode of care and finding different ways to batch is 
primarily what we hear from both the payers and providers which 
more closely align to their billing practices. And we believe 
the more in line you make practices, dispute resolution process 
with billing, you will get better results, and the parties will 
much more understand the process and they will come to much 
more resolutions, as well.
    Ms. VAN DUYNE. I appreciate that. When Congress drafted the 
No Surprises Act, this committee was very specific about what 
criteria should be used in IDR to settle the payment dispute. 
And this is something back in my home state of Texas that the 
Texas Medical Association has consistently advocated for.
    My question, Mr. Bobeck, is before the IDR process was 
halted, what criteria were used--were you using to determine a 
case?
    Mr. BOBECK. Congressman, do you mean before the Act's 
implementation, or the new court cases as they were going 
forward?
    Ms. VAN DUYNE. The new court cases in which IDR actually 
closed the portal.
    Mr. BOBECK. From the beginning of the process, the Act 
itself outlined very clearly the factors that had to be 
represented, one of which was the QPA, and the number two was 
what they called additional information. Additional information 
included various aspects, one of which was previous contracted 
rates over the last four years, the market share of both the 
payer or the provider, patient acuity of how they presented in 
a particular facility, the teaching status of that provider 
facility, the level of training, and, obviously, as we already 
mentioned, the QPA.
    Initially, when it came out, the rules written by CMS 
required that you look at the QPA first, as the first aspect of 
it, and then you would look at the other factors to see if 
there was some type of rebuttable presumption, if you will, 
upon the QPA.
    The court cases that came out in February made it very 
clear to the arbitrators that you were to look at all of these 
factors together equally. The weight that you give them is 
ultimately up to the arbitrator in that particular aspect. And 
so with those changes that come through the court cases, and 
then obviously the CMS rules, we have adjusted how we have to 
review those cases because that is the rules which we were 
given.
    Ms. VAN DUYNE. Dr. Bleier, real fast, would you say that 
this weight on the median in-network rate represents the unique 
circumstances of a case?
    Dr. BLEIER. If you are asking me if I think the QPA should 
be overweight, the answer is no.
    Ms. VAN DUYNE. All right. Thank you very much.
    Dr. BLEIER. Thank you.
    Ms. VAN DUYNE. And I yield back.
    Chairman SMITH. Mr. Kildee is recognized.
    Mr. KILDEE. Thank you, Mr. Chairman, for recognizing me and 
for holding this hearing. It is a very important subject.
    I share the views expressed by some of my colleagues, and 
my questions might be a little redundant. But as you can see, 
we sort of come and go, and I may have missed some of the 
answers.
    But as the ranking member, Mr. Neal, said, we knew with 
pretty good clarity what we were trying to produce when we put 
together this legislation. And it is something that was a 
bipartisan product, something that doesn't happen often enough 
around here. And it is something that we, you know, take a 
great deal of pride in. So it is a cause of a lot of 
frustration for us to not see the legislation being implemented 
consistent with what we know was, in fact, our legislative 
intent and what we actually think the legislation does a pretty 
good job of articulating. We want to see that adhered to.
    But if I could pose a couple of questions, one to Dr. 
Bleier and then another to Ms. Spicer, and you may have 
answered this before, but if you could just elucidate me on 
this subject a bit further.
    One of the obviously challenging areas that we are seeing 
with No Surprises Act is the rising reports of terminated in-
network contracts. And Dr. Bleier, you made mention of that. It 
obviously is a problem in terms of contributing to the 
challenges that we face in terms of trying to adjudicate these 
disputes.
    But it also would seem to me that it would have an effect 
on overall health care costs generally. And I wonder if you 
might comment on the extent to which you are seeing this, and 
how it is playing out in the field.
    And then, Ms. Spicer, more generally, I wonder if you have 
suggestions as to what the Administration might do, or what 
Congress may have to do to ensure that as we implement, we are 
not seeing a narrowing of providers that really does create a 
threat to patient care.
    So, starting with Dr. Bleier, if you could comment, and 
then Ms. Spicer.
    Dr. BLEIER. Sure. You know, as I stated earlier, I 
appreciate the question.
    There wasn't--we didn't have an out-of-network issue before 
the NSA. We were in network with all of the major carriers, and 
that was always our strategy. We don't want to have patients in 
the middle. We want to leave patients out of the middle during 
their most vulnerable times in their lives and their family's 
lives often times. And most of our contracts go back up to a 
decade or more.
    And we certainly didn't ask for any rate changes, despite 
there being no inflationary clauses, despite the transfer of a 
lot of responsibility to the patients as far as high deductible 
plans go. And the insurers didn't ask for rate changes, either. 
There was--most of those contracts were on evergreen, yearly 
renewals, and they signed them without question, until the NSA.
    Then the NSA comes out and, surprisingly enough, we really 
didn't think we would be affected by this very reasonable, 
well-crafted, bipartisan piece of legislation because we 
weren't out of network with anyone. We weren't part of this, 
you know, reported issue. But nonetheless, because of the NSA, 
ironically, we have then been kicked out of network by a couple 
of payers, and by a third payer as well, threatened, but 
thankfully, you know, did not actually ended up kicking us out 
of network.
    Mr. KILDEE. So just out of curiosity, ostensibly, what is 
the justification that is being offered for that, for taking 
that step?
    I mean, I understand what the reasoning might be behind the 
wall, but what is offered as the justification?
    Dr. BLEIER. There is no justification that I am aware of. 
It is a, you know, 40 percent-plus reduction in reimbursement 
if you want to stay in network.
    Mr. KILDEE. Right.
    Dr. BLEIER. And sometimes it is much less. And then, once 
we are out of network, it is a 70 percent reduction in the 
upfront payment. And then there is an IDR process which we 
can't really access and take advantage of.
    So it is an inherent--becomes a permanent loss of resources 
for our group to use towards patient care.
    Mr. KILDEE. Right. Ms. Spicer. Thank you, Doctor.
    Ms. Spicer.
    Ms. SPICER. Thank you for your question.
    In New York State, we have state laws that require robust 
provider networks. So I would suggest Federal laws are less 
robust in that area. So I would suggest network adequacy 
protections in the form--in that form.
    And also, one thing that advocates in New York State bring 
to our regulators often is surveillance of those networks. 
Sometimes consumers complain of ghost networks. And, of course, 
we still see misinformation regarding networks. And I would 
advise surveillance of networks to ensure that the networks are 
as robust as possible.
    Mr. KILDEE. Thank you for that, and I want to thank the 
panel for your contributions to this conversation.
    I want to thank the chair for holding this hearing. It is 
so rare that we come together. We should do more of this, we 
should come together around a really difficult issue and find a 
bipartisan solution. And it is my hope that folks down the 
other end of the street are listening to this, and will work 
with us to make sure that the law is being implemented in the 
way it was intended.
    With that, thank you, Mr. Chairman. I yield back.
    Chairman SMITH. Thank you. Mr. Smucker is recognized.
    Mr. SMUCKER. Thank you, Mr. Chairman, for yielding and for 
holding this important hearing today. And I think, as Mr. 
Kildee just said, you are hearing almost unanimously the view 
of members of this committee and from both sides of the aisle.
    This is an issue that--there was considerable work done 
back in 2020. You know, we all want to ensure that our 
constituents have access to quality health care, they have 
access to the care that they need and at a price that they can 
afford. We want them to understand the costs. And then we don't 
want them to be surprised with large bills that they weren't 
expecting. And so it is--we are all frustrated that this hasn't 
been carried out in the way that was anticipated when this bill 
was passed.
    And I am--again, I don't know that I have a lot more to add 
to this discussion other than what has already been discussed, 
but I represent an area in southeastern Pennsylvania, the 11th 
district in Pennsylvania, that has, you know, some large rural 
areas. And I am concerned about care being accessible there, 
and I am concerned about the impacts of this not being carried 
out properly, and how that impacts us.
    And I think, Dr. Bleier, you--I may ask you to expand on 
this, although you have you have sort of just addressed the 
question. But, you know, you have said, I think, 52 percent of 
claims are not even paid. And you testified that there is not 
even a clear mechanism right now to ensure that there is a way 
to force that payment to come. So it has got to have an impact 
on hospitals and providers' ability to carry out care.
    And so, again, as I said, I am concerned that--the impact 
this will have on patients who need to rely on your systems for 
their care. So I don't know if you want to expand on that at 
all. Have you had to alter or eliminate services? Do you know 
of other providers who have had to do that because you are 
being compensated at a slimmer margins than you should be, 
otherwise?
    Dr. BLEIER. I would hazard a guess that there are many 
groups out there that have had to do that, but I can't say for 
certain.
    As far as our group goes, you know, we are really trying to 
have a more medium sort of term view of this situation in the 
sense that we have--although our revenue has been slashed 
because of what has occurred, I think the owners of our group 
who all work in our emergency departments every month have 
taken the brunt of it. And we have tried to shield our nurse 
practitioners and physicians' assistants and other providers 
and administrative staff from that. But it can only go on for 
so long.
    And we are very hopeful, very hopeful, fingers crossed, 
that these Texas Medical Association lawsuits will actually 
bear fruit, that the regulation of this bipartisan piece of 
legislation will be implemented consistent with the intent of 
the law. And, if that happens, I am hopeful that, you know, we 
will be able to continue to provide the level of resources that 
we want to--all of our patients, including those, you know, 
generally under-resourced communities within our state.
    Having said that, though, if this continues, I don't see 
any way we can continue the level of care that we currently are 
providing. It absolutely will, for our group, lead to, 
unfortunately, reduction in hours, staffing hours, potentially 
reduction of positions entirely. It may even lead to us having 
to withdraw, unfortunately, from certain contracts where, you 
know, it is not sustainable. That undue pressure with that 
razor-thin margin is just too much.
    Mr. SMUCKER. So I think you have just articulated why this 
issue is important and why it is important we get this resolved 
as quickly as we can, why it should be implemented in the way 
that was intended. This will affect--and potentially is already 
affecting--individuals who need care who may not be able to 
access care because this issue is being carried out in a far 
different way than what was intended.
    So with that, I yield back. Thank you, Mr. Chairman.
    Chairman SMITH. Mr. Hern is recognized.
    Mr. HERN. I thank the chairman and the ranking member for 
hosting this bipartisan oversight hearing on surprise billing 
legislation.
    Almost three years ago, Congress passed the No Surprise Act 
to protect patients from surprise medical bills. Before this 
law you would hear stories of a patient being rushed to the 
hospital for an emergency, and then surprised with an out-of-
network charge. With the passage of this law we are seeing the 
private market work to negotiate claims and leave the patient 
harmless.
    I am proud I voted to support the No Surprises Act to end 
balanced billing and root out fraud in the system. Today I want 
to highlight another key provision in the No Surprise Act, the 
Advanced Explanation of Benefit tool, or the AEOB. The AEOBs 
are patient price estimator tools that empower consumers to 
shop for their health services by letting patients know the 
cost before--before--they get care.
    This Congress is focusing on building out transparency 
data. Still, until this information is personalized and 
considers the patient's health insurance coverage, this data is 
meaningless for everyday Americans. That is why it is so--why I 
am so disappointed this Administration is dragging its feet to 
implement the patient price estimator tools price required by 
the No Surprises Act.
    This committee has sent two bipartisan letters inquiring 
into the continued delays in providing patients with these 
tools. Mr. Chairman, I would like to insert for the record 
these two letters from the Ways and Means Committee to HHS 
inquiring about the delayed implementation of the AEOB.
    Chairman Smith. Without objection.
    [The information follows:]
 
     [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
         
    Mr. HERN. Thank you. Yet we have to get a clear answer 
about when we will see full implementation of this provision.
    Fortunately, innovators in my home state of Oklahoma are 
working to ensure Americans can navigate the opaque health care 
system. For example, Medefy Health in Oklahoma partners with 
over 1,500 employers to provide approximately 300,000 members' 
access to personalized cost estimates within the provider 
selection process. Consistently, this tool delivers significant 
health care cost savings to patients and the small business 
owners administering their health insurance. It is an absolute 
failure of this Administration to delay implementation of this 
technology elsewhere.
    Considering Americans' families' current economic 
struggles, anything to help with financial planning should be a 
priority. Knowing how much health services will cost removes 
some anxiety patients face when seeking medical care. Patients 
are nervous about their test results. There is no reason for 
the added anxiety of not knowing how much a service will cost 
them.
    Ms. Spicer, in your testimony you mentioned the importance 
of consumer protections and the shared story of a parent--a 
patient who was not given an advance estimate of the cost of 
this procedure. The patient received his explanation of 
benefits from his insurance company after the procedure, and 
therefore had no idea how much surgery--this surgery would cost 
in advance.
    Ms. Spicer, every day Americans shop for goods and services 
and know the costs in advance. Can you speak to the positive 
impact an Advanced Explanation of Benefits would have on 
patients?
    Ms. SPICER. Yes, thank you for your question.
    The Advanced Explanation of Benefits is a--would be a 
hugely positive tool for consumers to understand health care 
costs associated with the services they want in advance of 
getting those services. It would give them the ability to make 
informed decisions, considering their bank accounts and their, 
you know, other kinds of choices that they have in their health 
care before they incur these crushing--potentially crushing 
medical bills.
    In one of the examples in my testimony, I talk about the 
notice of consent waiver that is required for each--for--when 
you go to a practice, each patient gets a notice of consent 
waiver, and that will tell you if there is out-of-network 
providers potentially involved in your care. But it doesn't end 
that you may have out-of-network costs because of that, but it 
doesn't give you any specifics about those costs.
    It is also bundled with a bunch of papers that you sign 
automatically, that you have to sign to walk through the door, 
like the HIPAA release and the consent form, other consent 
forms. So it really--what is in place now doesn't necessarily 
give all that transparency and that information in order for 
consumers to make an informed decision.
    I would say that even the Advanced Explanation of Benefits 
form, consumers are going to need help understanding what it is 
because it is going to be complicated.
    Mr. HERN. I thank the chairman and the ranking member for 
working with us in a bipartisan way to make this happen.
    There is nothing in America that consumers purchase that 
they don't know what it is before the price of it, before they 
pay for it, except for their health care. It is time for us to 
get this resolved and fix this issue once and for all for the 
American people.
    Thank you, and I yield back.
    Chairman SMITH. Mr. Evans is recognized.
    Mr. EVANS. Thank you, Mr. Chairman. I want to thank the 
Ranking Member Neal for all his work on surprise billing over 
the years to help our constituents.
    Providing access to price information is important to 
Pennsylvania hospitals. In Pennsylvania, every hospital has a 
patient advocate for financial counsel. The individual is 
available to discuss pricing with everyone to clarify costs. 
Ms. Spicer, in your experience, how helpful would it be for the 
patients to have this kind of information to clarify costs when 
they leave the hospital?
    Is there other information that you think would be 
important for hospitals to provide?
    Ms. SPICER. Thank you for your question. Yes, it would be 
very helpful for patients to have advocates to explain to them 
costs. I think it would be even more helpful, as we discussed 
today, to have them in advance of the hospitalization.
    But certainly, in New York, we have a hospital financial 
assistance law, and there are offices within that--the hospital 
that are charged with extending that hospital financial 
assistance and giving other information like patient advocates 
offices. And we often at Community Health Advocates act as a 
kind of intermediary and get information and share it out so 
that consumers understand their rights, and also their 
potential costs, and the costs that they have incurred, right?
    We always get consumers who come to us to say, ``I don't 
understand why the bill that I am receiving is so high. How 
could the cost of XYZ be what is on this bill?'' Or the bill is 
for, you know, thousands and thousands of dollars, but the 
invoice doesn't tell me what is--what I received that they are 
charging me for.
    So, definitely, transparency in billing and pricing prior 
to being billed is needed.
    Mr. EVANS. Any thoughts you have in terms of implementing 
incentives to make it happen?
    Ms. SPICER. For the Advanced EOB, I can't speak to why it 
hasn't been implemented. I think it would be great for 
consumers, for--you know, for those pieces to roll out.
    Mr. EVANS. I yield back. Thank you, Mr. Chairman.
    Chairman SMITH. Mrs. Steel is recognized.
    Mrs. STEEL. Thank you, Mr. Chairman.
    Before Congress stepped in, a patient receiving emergency 
care from an out-of-network provider or facility would receive 
surprise medical bills. Seven in ten patients were unable to 
afford their out-of-network medical bills, according to a 
previous Kaiser Family Foundation survey.
    Unfortunately, this scenario happened to John Hagee, who 
survived a serious bicycle incident and had to visit an 
emergency room care in Los Alamitos. He received a $5,000 
medical bill for his visit and later discovered that the 
hospital and physician group were both out of network. John, 
like many others, had to face medical debt and significant 
financial burdens due to receiving vital care.
    The bipartisan No Surprise Act has been successful, but we 
can all agree that its implementation has not, leading to 
physician burnout and reduced patients' access to care.
    I have heard from physicians across California, 
particularly in emergency medicine, that issues with 
implementation of the No Surprises Act have caused such 
financial instability that many physicians are retiring early 
and leaving medicine.
    According to a local survey, 45 percent of California 
physicians said they are considering retiring early. Three out 
of four California physicians report patient challenges with 
timely access to care. And 60 percent of California physicians 
report difficulty staffing emergency on-call panels. Now 
patients are being onboarded in emergency rooms, waiting for 
specialists to become available.
    To Dr. Bleier and Mr. Budzinski, since the recent court 
rulings in Texas against the Administration's implementation of 
the No Surprises Act, the Independent Dispute Resolution 
process for resolving payment disputes were put on hold. Now in 
this month the Administration has announced that it expects to 
direct certified IDR Entities to resume issuing payments 
determinations for some disputes very soon. This means that 
providers are still treating patients without a mechanism to 
get fairly paid.
    For a provider, what does this freeze in the system do to 
you and to your practice?
    Dr. BLEIER. I appreciate the question. It puts us in a very 
difficult situation.
    You know, unfortunately, I think the insurers--and we all 
know that we emergency medicine providers and staff working in 
those emergency departments will take care to the highest level 
any patient that presents to the emergency department, no 
matter what, regardless of their ability to pay. We always do 
the right thing for those patients.
    However, we can only staff those emergency departments with 
the resources that are available to us. So when our 
reimbursement is slashed below market rates, longstanding 
market rates in our area, and our revenue and resources are 
dropped, we are not--and then we have no recourse--you know, 
the No Surprises Act, this wonderful, bipartisan piece of 
legislation set up this process by which we would have recourse 
in that situation when suddenly a payer, where we had been in 
network with them for a decade or more, suddenly slashes our 
reimbursement by 40 to 70 percent, we would have this ability 
to still advocate for ourselves and potentially still receive 
fair payment.
    But if we don't have--if our payments are reduced up front, 
and then we have no recourse, inevitably what is going to 
happen is we are not going to be able to staff those emergency 
departments and put the resources in that those patients and 
those communities need, which is most horrible for our patients 
but, as you alluded to with some of your constituents, horrible 
for the providers and nurses and other staff working in those 
emergency departments who want to do what is right for those 
patients.
    Mrs. STEEL. Thank you, Dr. Bleier.
    Mr. Budzinski.
    Mr. BUDZINSKI. Yes. Thank you, Representative.
    We are a large organization. But as I mentioned earlier 
today, the amount of reimbursement that we have tied up with 
the IDR process that is broken is over $40 million in under-
payments to our organization. And even an organization our 
size, these are substantial amounts of funds that ultimately 
require us to balance our budgets in some way, shape, or form. 
And this ultimately missing revenue does impact our resource 
allocation. There is no question about that.
    Mrs. STEEL. Thank you very much.
    Mr. Chairman, I have another question but my time is up, so 
I am going to yield back. But I am going to ask for the 
recording of my question.
    Chairman SMITH. You can definitely submit the question in 
writing----
    Mrs. STEEL. Thank you.
    Chairman SMITH [continuing]. And they will answer that.
    Chairman SMITH. So----
    Mrs. STEEL. Thank you.
    Chairman SMITH. Thank you, Mrs. Steel. Mr. Feenstra is 
recognized.
    Mr. FEENSTRA. Thank you, Chairman and Ranking Member. Thank 
you for the panel for being here today.
    You know, we have challenges. We all see it. We understand 
it. We know there are flaws. My question--I want to really 
center around the batching. When you start looking at the 
various departments, to batch claims to avoid the buildup and--
but the problem really becomes the implementation of the 
batching.
    So, Mr. Bobeck, in your testimony you mentioned about 75 
percent of disputes were determined ineligible due to non-
compliance with the Administration's batching rules. Can you 
describe the eligibility criteria for determining validity of 
these claims?
    I mean, what can be done here?
    Mr. BOBECK. Congressman, thank you for the question.
    Currently, right now, the eligibility is actually at 87 
percent. So most of the cases are actually eligible. But of the 
percentage of cases that are determined eligible, batching is 
accurate as one of the reasons many cases are ineligible. And 
it does not result from the parties not trying to give their 
best efforts; it revolves around the parties trying to comply 
with how batching has to be done.
    So, for instance, most of the codes, service codes that 
come through to an IDRE can be centered around 5 codes, 999281 
through 999285. Those codes, you can batch those together when 
they are the exact same service code, and they involve the 
exact same health plan, the exact same provider, and also they 
come within the same 30-day timeframe.
    That just simply is not how providers and payers track 
their claims. They don't track them over all of these different 
patients. They track a patient's claim and all the ancillary 
care that goes along with that. So it is a different mindset 
that has been enacted under the rules, and therefore that is 
what they have to comply with. And that is what they have to 
spend a lot of their time just to get information to an IDRE.
    And when we get that information, we can only say whether 
or not that claim was done accurately or not, based upon what 
was provided to us. So it provides not just challenges for the 
IDREs, but, again, for the patient providers. And that is what 
leads to ineligibility. It is not good faith efforts, it is 
just simply an inability to track cases as they are accustomed 
to, to be quite frank, over the last several decades.
    Mr. FEENSTRA. So, Dr. Bleier, in what Bobeck just said, 
what can we do to ensure that providers probably can use a 
batching process in a meaningful way?
    To me, there is merit here, but how can we get it done?
    Dr. BLEIER. That might be a little bit above my pay grade. 
[Laughter.]
    Dr. BLEIER. I think simplifying processes, in general, is 
beneficial. You know, I think sometimes in these regulatory 
processes they can be uber-complicated and difficult for 
providers to follow. Certainly, a lot of providers, you know, 
will use revenue cycle management companies to submit a lot of 
those payments. So, you know, the--batch those claims.
    So it is a little bit outside my wheelhouse. But in 
general, I think simplifying the process, making the process 
more transparent on the submission side, I think, is always 
generally----
    Mr. FEENSTRA. Yes, I would agree. I mean, I think 
transparency--and I just see all the red tape, all the issues. 
I mean, I think we can make this simpler, and make it more 
efficient.
    Budzinski, similar. Can you describe what batching 
procedures would help hospitals in their IDR processes?
    I mean, what are some--I am trying to aim at solutions 
here. That is what I am trying to do.
    Mr. BUDZINSKI. We greatly appreciate that, Representative, 
and thank you for the question.
    So, as we said earlier, hospitals for emergency-type care 
are typically paid on a case rate basis. Okay? Observation 
care, post-emergency as a continuation is a case rate basis. 
Inpatient care is a case rate. So that is how we are typically 
reimbursed, not CPT code by CPT code by CPT code by CPT code.
    So the current process, the current process is required. In 
order to batch, you have to have the same exact CPT codes for 
every single patient with the same payer, the same exact 
identical care for every----
    Mr. FEENSTRA. That doesn't happen very----
    Mr. BUDZINSKI [continuing]. Every--it doesn't happen at 
all. Every patient is different.
    Mr. FEENSTRA. Yes.
    Mr. BUDZINSKI. Every patient has unique needs. So what we 
would be an advocate for is go back to a structure of batching 
and bundling that is consistent with how hospitals are 
reimbursed.
    For example, emergency department visit, level one, level 
two, level three, level four, level five. It is a case rate, 
and that is how we are typically reimbursed. The CPT codes and 
all the ingredients are not really relevant. It is about the 
patient and the care, the level of care that patient is 
receiving. That is an example. Observation case rates would be 
another example.
    Batching based upon how we are typically reimbursed would 
be ideal, and that would simplify the process and, I think, 
help--we think help reduce future backlogs by reducing the 
number of----
    Mr. FEENSTRA. That is right.
    Mr. BUDZINSKI [continuing]. Of determination requests.
    Mr. FEENSTRA. See, boom, we got a solution. We can do this. 
I mean, it is not rocket science.
    But thank you, and I yield back.
    Chairman SMITH. Mr. Panetta is recognized.
    Mr. PANETTA. Thank you, Mr. Chairman, I appreciate you 
holding this hearing. And of course, thank you, Member Ranking 
[sic] Neal, for all your work on this important issue.
    And, ladies and gentleman, thank you for your patience and 
your testimony and your information about the issues and 
potential solutions for implementation of this very, very 
impactful bill--at least we want it to be impactful.
    I come from the central coast of California, in the 19th 
congressional district. And when I am talking to my patients 
there, the number-one thing that I hear about is access to 
care. But I also talk to providers in my district. And the 
number-one thing I hear about from them is payment issues.
    Now, I think that we know the intent of the No Surprises 
Act was to address a practice of balance billing that, 
unfortunately, decimated families' finances and limited access 
to care. But with the reports of a long and often arduous 
arbitration process, it is clear that there is more work to be 
done, as we are hearing today and, obviously, as you know. And 
that is why we want to try to ensure that we are truly 
improving access and, of course, lowering cost.
    One of the lessons that I have learned in my limited time 
in Congress is that we can do a real good job of passing 
legislation, but we need the Federal Government to do an 
excellent job when it comes to implementing that legislation. 
And, unfortunately, today, as to what we have heard and what we 
know, this is a good example of that not happening.
    Now, a key component of an effective Independent Dispute 
Resolution process is timely payment by the losing side. Under 
the No Surprises Act, that payment is supposed to happen within 
30 days. However, a recent survey by the Emergency Department 
Practice Management Association found that 87 percent of payers 
did not meet this requirement. And obviously, as you know, that 
threatens the financial stability of already stretched 
providers like the ones that I represent.
    Dr. Bleier, in your testimony you mentioned the impact of 
slow reimbursement by providers. How do these delayed payments 
impact providers?
    And if you could, I know my colleague mentioned benefits, 
but how do you feel about the Administration penalizing parties 
that don't pay within the required period?
    Dr. BLEIER. Well, you know, it is a structural loss for us 
the way that this has been rolled out, unfortunately. You know, 
we--there is no way to claw back any of that revenue that we 
have already lost, unfortunately.
    As far as your comment on--or your question concerning 
whether there should be some type of penalty, it--whatever will 
ensure that, you know, the arbitrator rulings are followed in a 
timely fashion, consistent with the legislation, certainly 
seems reasonable to me.
    We are expected to make our payments up front as far as 
arbitration fees. We do that in timely. We are the ones where 
the onus, despite receiving an upfront payment--again, 40 to 70 
percent less than what we have historically gotten for years 
and years and years--we are the ones where all the onus is on 
us to make that submission, to complete the paperwork, to 
complete the appropriate documentation. It seems only fair, I 
would--from my point of view, certainly--to expect that the 
other parties involved, as well, are held to a similar 
standard.
    Mr. PANETTA. Great. Thank you, Dr. Bleier, I appreciate 
that.
    Mr. Chairman, thank you again. I yield back.
    Chairman SMITH. Ms. Malliotakis is recognized.
    Ms. MALLIOTAKIS. Thank you very much. Thank you, Mr. 
Chairman. Thank you to the witnesses.
    The No Surprises Act was a major bipartisan achievement, as 
was discussed from my colleagues on both sides of the aisle. 
But, you know, the goal was to protect patients from receiving 
these exorbitant bills from out-of-network care, often without 
their knowledge and consent. And the establishment of the 
Independent Dispute Resolution spearheaded by this committee 
was designed to provide a fair mechanism for settling the 
payment disputes between the providers and insurers.
    However, as has been mentioned, in its implementation 
unelected bureaucrats have gone against the congressional 
intent and created a lopsided dispute resolution process which 
favors health insurers over the medical providers. Medical 
providers are now being forced to accept artificially low 
payments, leading to reduced staffing and exacerbating rural 
and underserved workforce shortages.
    I am also continuing to hear from providers in my home 
state of New York that--over the backlog of dispute resolution 
claims waiting to be resolved. Recent surveys find that 91 
percent of filed IDR claims remain open and unadjudicated.
    CMS has recognized that the primary cause of delays in 
processing disputes has been the complexity of determining 
whether disputes are eligible for Federal IDR process. They 
found that the health plan type was unknown upon dispute 
initiation in more than half the disputes, causing certified 
IDR entities to conduct additional outreach and further 
delaying the eligibility review process.
    I will start with Mr. Bobeck.
    Do you believe that there is additional information that 
could be provided that would help expedite this process and 
help providers determine claim eligibility?
    Mr. BOBECK. Thank you very much for the question. Yes is 
the answer to your question.
    During the open negotiation process, this follows the 
process by which a provider has received a payment that they 
disagree with. They have a 30-business-day open negotiation 
process. What is supposed to be happening during that process 
is the parties should be sharing that type of information.
    As an example, you mentioned parties don't know which 
health plan. If you are a TPA, let's say you are a TPA who 
represents several health plans, self--many self-insured funds. 
The provider themselves does not actually know who the health 
plan is. They just see the TPA, they see a name, and then they 
see other cases and they think that is all the same health 
plan. It is not. There are different ones.
    Parties are supposed to be sharing that type of information 
throughout the process. And the more that they share that, the 
more that they understand who they are dealing with, and then 
those claims--we have seen it time and time again, it makes for 
a much better IDRE process. You don't see delays in those 
cases. You see timely and very quick adjudications.
    Ms. MALLIOTAKIS. And what portion is the backlog attributed 
to states like New York that have their own surprise billing 
laws already in place?
    And what is the current process for determining state or 
Federal IDR eligibility?
    Mr. BOBECK. When it comes to ultimately--right now, most of 
the cases are coming from other states, as Texas. Texas, like 
New York, also has its own surprise billing law, as well. But 
that does not prevent cases still coming into the system that 
are not captured by that state process.
    When it comes to the backlog, again, we currently don't 
have one, but there is one that has been newly created simply 
by the portal not being open. And with the portal not being 
open, providers and payers cannot resolve their disputes and 
move forward.
    Ultimately, when it comes down to the state process and 
which state process applies, there are regulations, there are 
rules to--which apply. But ultimately, those rules are not 
always even clear to the parties. We always, again, have to say 
that we are like a judge. We can only go on the evidence as 
provided to us. The parties have to provide that evidence to 
us, as well as what we can find about whether a state process 
applies or not.
    Ms. MALLIOTAKIS. Thank you.
    Dr. Bleier, on that note, would including remark codes like 
CARC or RARC help to ease the current backlog?
    Dr. BLEIER. I think it would. I think anything, again, that 
promotes transparency on the provider submission side would be 
incredibly helpful.
    Ms. MALLIOTAKIS. Okay. And Ms. Spicer, I understand you are 
a constituent of mine from New York. It is great to have you 
here. How has the experience been for patients in New York 
navigating both the state and the Federal patient protections?
    Ms. SPICER. So in New York we had our own system prior to 
the NSA. I think we--it took a couple of years to get it off 
the ground, and there are still issues with it. But I--
consumers in New York now that are--we have many, many 
consumers in New York, especially in New York City, in the five 
boroughs, that have self-insured plans. And they are--the NSA 
applies to them specifically. They use those Federal processes 
and they appeal if they are not held harmless for surprise 
bills, and they are dealing with how to navigate those two at 
once.
    Ms. MALLIOTAKIS. So it is my understanding, based on the 
whole conversation today, more transparency, more information, 
being more forthcoming with whether these are state or Federal 
would be helpful in the matter. And also contributing to the 
high volume of claims moving through the IDR process is that 
there hasn't been a meaningful, open negotiation period, which 
is supposed to help address these out-of-network claims.
    I thank you all for your time, and I look forward to 
working with our committee to address these issues.
    Chairman SMITH. Mr. Carey.
    Mr. CAREY. Thank you, Mr. Chairman and Ranking Member Neal, 
for bringing together--and all of you--for being here today and 
going through this many hours of questioning. It has been 
enlightening.
    You know, the flawed implementation of the No Surprise Act 
has created burdensome and often confusing guidance for health 
care providers, including those that are in my home state of 
Ohio. This is leading to patients facing longer wait times, 
increased health care facility closures, and exacerbating 
workforce shortages, ultimately reducing access for those in 
the rural and underserved areas, particularly in my district. 
Today we have heard from many of those providers who are 
impacted, and see the harm caused by the poor implementation of 
the No Surprise Act.
    Dr. Bleier, my question for you, Congress created an open 
negotiation, a 30-day period, for payers and providers to 
settle the disputes before a third party would step in. How has 
this open negotiation designed in the law worked for your 
practice, or maybe not worked?
    Dr. BLEIER. So my understanding and discussion with our 
revenue cycle management company is that there has been 
effectively no response on any of the submissions from the 
insurers.
    Mr. CAREY. Interesting. Okay.
    Ms. Spicer, I want to compliment you on bringing up the 
name of one of the people in your written testimony who was a 
concert pianist and who had also--we had some time, I Googled 
her, and I would ask all my colleagues to do the same. She is 
very talented. But it really shows you the face of what happens 
to people that, really, you would think something like that 
would not happen to.
    I just have a couple of questions. I have one question for 
you. But the No Surprise Act was signed into law in late 2020 
to give patients the peace of mind that they won't receive a 
surprise medical bill weeks or months after they thought they 
were covered in a network service. Since the enactment--and I--
some of my colleagues have asked this in a roundabout way, but 
since its enactment almost three years ago, how have patients 
benefited from this law?
    Ms. SPICER. Thank you for your question.
    Patients like Claudia have benefited hugely in being 
protected from out-of-network bills that--our New York State 
law would not have protected Claudia, did not protect Claudia 
because it was based on network directory misinformation. She 
received her $35,000 bill, and the NSA does protect consumers 
against network directory misinformation.
    Also, you know, thousands and thousands of consumers are 
held harmless for out-of-network emergency service bills as a 
result of the NSA.
    Mr. CAREY. So do you have any--
    Ms. SPICER. And air ambulance bills are also----
    Mr. CAREY. Yes.
    Ms. SPICER [continuing]. An inclusion that New York's law 
did not have.
    Mr. CAREY. So do you have any concerns that patient access 
to care, which is already in jeopardy due to the health care 
workforce challenges that we face, will be diminished due to 
the implementation of this law at all?
    Ms. SPICER. At Community Health Advocates we see access to 
care issues every day. We have--I have, in my career of 24 
years, I have always had clients who call me and say, ``I 
can't--I want--I don't--I can't find a provider in my network'' 
that does a certain thing. So I--it seems that if this process, 
the arbitration process, isn't fixed, that that could be a 
result.
    Mr. CAREY. Okay. And thank you again. Thank you to the 
witnesses.
    And Mr. Chairman, I yield back.
    Chairman SMITH. I would like to thank our witnesses for 
appearing here today. I appreciate your testimony and your 
several hours of endurement.
    Please be advised that members have two weeks to submit 
written questions to be answered later in writing. Those 
questions and your answers will be made part of the formal 
hearing record.
    With that, the committee stands adjourned.
    [Whereupon, at 1:56 p.m., the committee was adjourned.]
      

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