The United States Centers for Medicare and Medicaid Services (CMS) Center for Consumer Information and Insurance Oversight recently issued a report on health insurance market reforms, including the Affordable Care Act (ACA) and the No Surprises Act (NSA). According to the report, as of June 30, 2024, CMS received more than 16,000 complaints under its jurisdiction related to Title XXVII of the Public Health Service (PHS) Act, most of which are related to alleged violations of NSA requirements. The report also indicates the number of complaints not under CMS’ jurisdiction but that were subsequently referred to the appropriate entity (without information regarding the resolution).
The Center for Consumer Information and Insurance Oversight within CMS is responsible for implementing many aspects of the ACA, including provisions related to private health insurance. Under the No Surprises Act, as of January 1, 2022, consumers have new protections when receiving emergency care, non-emergency care from out-of-network providers at in-network facilities, and air ambulance services from out-of-network providers. Under the NSA, excessive out-of-pocket costs are restricted and emergency services must be covered by insurance without prior authorization, irrespective of whether a provider or facility is in-network.
To compile the report, CMS considered “complaints” all information received regarding potential federal law violations, including information from stakeholder feedback, referrals from Congress, referrals from individual states or territories, No Surprises Help Desk complaints, and news articles.
The total number of complaints received was 16,073, with 3,373 of those remaining open at the time of the report. Of the 12,700 complaints closed, 4,438 were closed with no violation found and 400 were closed with a violation found. CMS notes that CMS has directed various plans, issuers, providers, health care facilities, and providers of air ambulance services to take action to address instances of non-compliance, resulting in roughly $4,183,383 in monetary relief paid to consumers or providers.
The three most common complaints against non-federal government plans and insurers were: non-compliance with qualifying patient amount (QPA) requirements (1,035 complaints); late payment after independent dispute resolution (IDR) determination (675 complaints); and non-compliance with 30-day initial payment or notice of denial of payment requirements (390 complaints).
The three most common complaints against providers, facilities, and providers of air ambulance services were: surprise billing for non-emergency services at an in-network facility (4,286 complaints); surprise billing for emergency services (2,577 complaints); and good-faith estimate (1,922 complaints).
Importantly, because CMS does not disclose information about ongoing investigations, the data within the report is limited to complaints that are closed by CMS.