In this presentation, I have attempted to underscore how this faulty piece of legislation has the potential to ultimately limit access to care.

1. Prizma Analytics Inc.
NO SURPRISES ACT 2022
A FAST-DEVELOPING BURNING
PLATFORM
JAY RAY
PRIZMA ANALYTICS INC.
APRIL 10, 2023

2. Prizma Analytics
Inc
HEALTHCARE CONTRACTS – IN NETWORK
• Procedures
• Physician services
• Anesthesia
• Radiology
• Lab Tests
• Drugs
04/10/2023 Slide: 2
Fee For Service Bundled Services Value-Added
• Payor reimburses hospital
• Hospital reimburses other
providers
• Hybrid models
• Usually as overlay
• Coordinated care
• Costs & savings tracked
• Sharing of savings
• Providers are organized state by state (legal entities)
• 177 million covered lives through employment sponsored plans that are covered under Federal ERISA laws
• Marketplace health plans are governed by state insurance laws
• Government payors include Medicare, State Medicaid, Tricare, Veteran Affairs, Indian Health Services

3. Prizma Analytics
Inc
OUT OF NETWORK (OON)
Slide: 3
• New provider or plan
• Small provider – not enough administrative bandwidth
• Plan focuses on building network with largest and most critical providers – rest remain OON
• Provider chooses to stay OON with expectation of higher reimbursement by plan or through ‘balance billing’
• Of late, some of the largest plans have canceled contracts with large providers – a fallout of the NSA
Why OON?
*** Discussion – Common practices around contracting & balance billing ***
Balance Bill to
Patient
Billed Gross Charges for each
line of service provided
Less Actual amount reimbursed by
OON plan
=
04/10/2023

4. Prizma Analytics
Inc
AFTER FIRST YEAR OF IMPLEMENTATION
Slide: 4
The No Surprises Act Is Vague and Confusing, and Congress Must Fix It
In seeking to appease special interests on both sides of the “surprise billing” debate, Congress devised a
complex and deeply flawed system that each side is seeking to turn to its advantage. Instead of requiring
three powerful and well-financed economic actors—insurers, doctors, and hospitals—to negotiate privately
over medical fees, the No Surprises Act instituted a novel system with vaguely defined standards that are
sowing confusion and litigation. Congress should amend the No Surprises Act to eliminate the dispute-
resolution process in favor of a truth-in-advertising approach that will protect consumers and liberate doctors,
insurers, and arbiters from confused and conflicting standards for resolving disputes that the disputing parties
can best resolve themselves.
The Heritage Foundation
Health Care Reform, Jan 24, 2023
No Surprises Act was implemented on Jan 1, 2022, to protect patients from large surprise
bills
https://www.heritage.org/health-care-reform/report/no-surprise-the-no-surprises-act-vague-and-confusing-and-congress-must
Source:

5. Prizma Analytics
Inc
UNPACKING THE ISSUE
Slide: 5
 Industry trends and history of legislative actions
 Overview of the No Surprises Act
 What has worked
 What is not working
 Why did it go wrong?
*************** Group Discussion ****************

6. Prizma Analytics
Inc
INDUSTRY TRENDS AND HISTORY OF LEGISLATIVE ACTIONS
04/10/2023 Slide: 6
Emergency Medical
Treatment and Active
Labor Act – 19861
• Initial intent – to prevent dumping of uninsured patients to county hospitals. Over time morphed into
more comprehensive set of rules governing patient care for all
• Extended beyond Emergency Departments
• Would serve as the anvil for the hammer to fall 35 years later!
Industry
Trends
• Patients treated at in-network hospitals also received bills from out-of-network providers
• The Affordable Care Act attempted to address balance billing – but had gaps
• Historically these bills were not necessarily unreasonable – a few bad actors always there
• Consolidation of physician groups – increase in private equity owned staffing companies
• ‘Balance billing’ for out-of-network services caught national headlines – Yale Study2
• The practice impacted patients visiting Emergency Departments the most
Through 2021
Multiple legislative
actions taken between
2019 and 2021
• In May 2019, President Trump called upon Congress to address ‘surprise billing’
• Between 2019 and 2020 bills introduced to address ‘surprise billing’
• December 2020 – No Surprises Act is passed into law
• July – Oct 2021 – Proposed and Interim Final Rules published.
• September 2021 – ‘Independent Dispute Resolution’ process defined
• No Surprises Act went into effect on January 1, 2022
Pre-1986-87
• Physicians at Cook County Hospital, Chicago published articles on dumping of uninsured patients
• Dumped from private hospitals to County hospitals
• Dumping defined as limiting/denial of medical services for economic reasons
• The practice subsequently found prevalent across the country
1https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1305897/
2https://medicalethicshealthpolicy.med.upenn.edu/in-the-news/unitedhealthcare-guided-yale-s-groundbreaking-surprise-billing-study

7. Prizma Analytics
Inc
AN OVERVIEW OF THE NO SURPRISES ACT
04/10/2023 Slide: 7
Protects patients from ‘balance
billing’ or unexpected medical
billing by:
• Emergency OON providers treating patients in In-Network facility
• Non-emergency OON service providers treating patients in In-Network facility
• OON providers of air-ambulance services
Patients responsible for what they would have paid as in-network out-of-pocket
Rules apply to group health
plans, plan issuers, and
healthcare providers:
• Fully insured private insurance (BCBS, UHC, Cigna, Aetna, etc.)
• Self Insured employer sponsored plans
• Healthcare facilities, providers including physicians and air ambulance providers
• Provide patients with information to be consumer advocates (Good Faith Estimates)
• Novel standard set for reimbursement by insurance to OON provider
• Independent Dispute Resolution (IDR) process between OON provider and plan
• Defined timeline for OON reimbursement and resolution
Overview of IDR process
• Insurance makes payment to OON provider
• Provider can dispute payment – 30 days open negotiation period
• Either party can invoke IDR after 30 days
• Certified IDR Arbitrator determines final payment
• List available on CMS website (fees $300 to $500 per claim)
• Provider can batch multiple claims (complex batching rules)
• Baseball style arbitration
• All parties subject to complex procedural rules of IDR

8. Prizma Analytics
Inc
WHAT HAS WORKED
04/10/2023 Slide: 8
• Patient objectives have been met for the most part
• ‘Balance Billing’ by OON providers has virtually stopped - unless patient has explicitly approved service by OON provider
• Patient education piece partially met and somewhat of work-in-progress

9. Prizma Analytics
Inc
WHAT IS NOT WORKING – PROVIDER REIMBURSEMENT
04/10/2023 Slide: 9
• Change in payor behavior – payors have lost interest in maintaining in-network status with providers
• IDR process overwhelmed due to explosion in number of OON payment disputes. As on December 5, 2022:
• Only 11,000 disputes resolved, and 23,000 cases dismissed by IDR entities
• Backlog of 130,000 unresolved disputes still outstanding1
• Government raised non-refundable fees on disputing parties from $50 in Jan 1, 2022, to $700 effective 20232
• IDR process mired in lawsuits3 driving up costs but not necessarily simplifying OON reimbursements
• Huge costs added to revenue cycle processes of providers to keep track of disputes and follow through on outcomes
• Huge negative impact on cash flow of staffing companies and independent provider groups
• Unconfirmed reports of some providers not staffing hospitals, due to staff shortage – ultimately impacting access to patient care.
The entire industry of providers getting reimbursed by private insurers and self-insured plans have
been disrupted in a manner that requires legislative fix – to avoid long term issues with access to
care.
1https://www.heritage.org/health-care-reform/report/no-surprise-the-no-surprises-act-vague-and-confusing-and-congress-must
2Article by Nick Hut published in hfma: Health Plan Payment and Reimbursement, dated December 20, 2022
3https://www.aafp.org/pubs/fpm/blogs/gettingpaid/entry/surprise-bill-arbitration-decision.html

10. Prizma Analytics
Inc
WHY DID IT GO WRONG?
04/10/2023 Slide: 10
Fundamentals
Ignored
• Insurers like to have as large a network as possible – to attract members
• Balance billing in OON setting adversely impacted patients – driving switching plan
• This market dynamics ensured insurers had interest in maintaining and growing the network
Unwittingly putting one
party in the driver’s
seat
• By attempting to derive OON rates, Govt assumed that such information is broadly available to all
• In reality, Healthcare pricing is opaque and highly dependent on case-by-case situation
• Insurers (and not providers) have market data of in-network and OON reimbursements
• Resulting abuse of process by payors – because they can
Ignored State-level
legislation that works
better
• Texas Department of Insurance (TDI) banned balance billing starting dates of service January 1, 2020
• Reliance on Fair Health rates in dispute resolution process is the key difference
• Fair Health is a non-profit, that maintains the nation’s largest private healthcare claims data repository
Infrastructure
Issues
• Minimal legislative and enforcement oversight
• Fragmented, complex and unworkable IDR process at volume
• High IDR fees
Attempt to legislate
disputes between
private parties
• To the extent balance billing was prohibited the law is a success
• Then it also legislated a novel mechanism to resolve disputes between OON parties through arbitration
• Ignored complexity of healthcare in developing IDR process & baseball style arbitration

11. Prizma Analytics
Inc
DISCUSSION
04/10/2023 Slide: 11