Reston, VA – A new Harvey L. Neiman Health Policy Institute study found that neurointerventionalists, who often deliver lifesaving and disability-sparing treatments for emergency stroke cases, have essentially no financially viable access to payment recovery through the No Surprises Act (NSA) for professional mechanical thrombectomy (MT) out-of-network (OON) claims. MT is an effective treatment for emergent large vessel occlusions, such as ischemic stroke. This Journal of Neurointerventional Surgery study was based on 1,000 simulated years of OON MT claims.

Patients having a stroke or other occlusive blood clot do not have time to select their care provider based on their insurance network. The federal NSA was enacted to protect patients from surprise medical bills when circumstances were beyond patients’ control. However, in effect, insurers decide what to pay based on what they consider the typical in-network rate. Physician practices have one channel to recoup payments from unfair insurance underpayment, the independent dispute resolution (IDR) process, but it comes with hefty fees. However, batching multiple OON claims together in the process can spread out those fees. This study evaluated the likelihood that neurointerventionalists can, given their stroke center volume, batch MT claims to spread out IDR costs and make the process financially viable.

The researchers found that, regardless of stroke center size, the IDR process was not viable for a vast majority of even global MT claims, which include both the professional and facility costs. Specifically, only 13.2%, 6.1%, and 3.3% of claims for large, medium, and small stroke centers, respectively, were shown to recover payments that would exceed IDR fees according to the modeled data. The researchers found no opportunity batch claims for only professional costs in a sufficient quantity to at least recover IDR costs.

“The expected cost of the IDR process is $235 if only one claim is submitted, and $281 if multiple claims are submitted in the same batch, “stated first author, Jonathan Grossberg, MD, vascular neurosurgeon and assistant professor at Emory Healthcare. “Hence, it is financially unwise for a neurointerventionalist to submit OON claims to the IDR process unless they expect payment recovery will be at least as much as the costs of entering the IDR process. This means they would need to batch at least 4 professional claims or at least 2 global claims before they can expect payment recovery more than IDR costs.”

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