As healthcare providers navigate a challenging policy landscape, recent updates on Medicaid expansion, the No Surprises Act (NSA), and advocacy opportunities have significant implications for the industry. In a recent webinar hosted by ImagineSoftware, Aron Goldfeld, Corporate Vice President and Advocacy Officer at TeamHealth, unpacked these critical topics, emphasizing the importance of engagement and adaptation in the evolving regulatory environment.
Medicaid Expansion: Incremental Steps Amidst Ideological Divides
While Medicaid expansion remains a contentious issue, some states are exploring innovative, albeit conditional, approaches to broadening their coverage. Aron highlighted that these initiatives often come with stipulations, such as work requirements, drug testing, and additional household status checks beyond income qualifications.
“States with fundamental differences from the Biden administration are experimenting with incremental changes,” Aron explained. These conditional measures reflect ongoing ideological divisions but also signal potential progress in bridging Medicaid gaps in states that have yet to fully expand their programs.
Aron also pointed to broader deregulation trends that may impact providers in 2025. “We can expect to see reduced regulatory burdens in areas like private sector delivery, transparency, and state-level flexibility,” he noted.
These changes could pave the way for innovation but require providers to stay informed and proactive.
No Surprises Act: Reshaping Provider-Payer Dynamics
The No Surprises Act (NSA), designed to curb surprise medical bills, continues to reshape provider-payer dynamics. Aron provided a comprehensive overview of the act’s key components, including:
- Surprise Billing Ban: Prevents out-of-network billing for emergency care and services at in-network facilities.
- Independent Dispute Resolution (IDR): A baseball-style arbitration process for resolving payment disputes between providers and payers.
- Qualifying Payment Amount (QPA): Central to arbitration proceedings, serving as a benchmark for fair payment resolutions.
Aron underscored the overwhelming response to the NSA. “The government anticipated 17,000 IDR claims per year,” he explained. “But in 2024 alone, providers are expected to file 1.4 million claims.” While providers are prevailing in over 90% of cases, the process remains fraught with delays, averaging six to nine months for resolution.
Challenges persist, including payer assertions that ineligible claims are clogging the system and provider frustrations over incomplete resolutions. Aron emphasized the need for the government to release a long-awaited final operations rule to streamline IDR processes. “Transparency and enforcement are critical to reducing backlogs and achieving fair outcomes,” he said.
Texas Medical Association (TMA) Litigation: Defending Provider Rights
Aron also touched on the ongoing litigation efforts spearheaded by the Texas Medical Association (TMA). These lawsuits challenge rulemaking under the NSA, particularly regarding the QPA’s role in arbitration and administrative fee structures.
Recent appellate rulings have tempered the TMA’s earlier successes, but Aron stressed that providers must remain unified. “Collaboration is key to challenging overreaching regulations and ensuring the NSA aligns with its statutory intent,” he urged.
Key Advocacy Opportunities for 2025
Aron concluded the webinar with actionable recommendations for healthcare providers:
- Prevent a Government Shutdown: Support legislative efforts to pass a continuing resolution or omnibus bill to avert funding disruptions.
- Address Medicare Cuts: Back H.R. 173, a bill that would mitigate the 2.93% reduction in Medicare reimbursement rates.
- Extend ACA Subsidies: Advocate for the renewal of marketplace subsidies to sustain access for low-income populations.
- Engage with the IDR Process: Despite its challenges, Aron encouraged providers to “stay the course” with the IDR system, calling it “the best available tool for resolving out-of-network claims and achieving fair contracts.”
- Push for CMS Oversight: Demand greater accountability for payer practices and enforcement of transparency requirements.
“Never underestimate the value of advocacy,” Aron emphasized. “Reaching out to your representatives and supporting key legislation can drive meaningful change.”
Final Thoughts
In a tough financial and regulatory environment, providers must remain vigilant and engaged. From Medicaid expansion to NSA implementation and beyond, the decisions made in the coming months will profoundly shape the future of healthcare delivery. For those navigating these challenges, Aron’s advice is clear: “Be patient, stay informed, and advocate relentlessly for policies that support the provider community.”
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All information contained herein is intended as general introductory information, is provided for informational purposes only, and is not legal advice. It should not be construed as legal advice and should not be relied upon as such. If necessary, please contact an attorney to obtain advice with respect to any particular issue or problem that may be related to the subject matter herein. The ideas and opinions expressed herein are the ideas and opinions of the individual author and may not reflect the ideas or opinions of ImagineSoftware, Technology Partners, LLC or any of its affiliates or subsidiaries.