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Socioeconomics
Original research
Neurointerventional payment for out-of-network mechanical thrombectomy in the era of the No Surprises Act
  1. Jonathan A Grossberg1,
  2. Eric W Christensen2,
  3. James M Milburn3,
  4. Guilherme Dabus4,
  5. Richard E Heller III5,
  6. Joshua A Hirsch6
    1. 1 Neurosurgery and Radiology, Emory University School of Medicine, Atlanta, Georgia, USA
    2. 2 Harvey L Neiman Health Policy Institute, Reston, Virginia, USA
    3. 3 Radiology, Ochsner Medical System, New Orleans, Louisiana, USA
    4. 4 Baptist Health Miami Neuroscience Institute, Miami, Florida, USA
    5. 5 Radiology Partners Inc, El Segundo, California, USA
    6. 6 Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
    1. Correspondence to Dr Jonathan A Grossberg; jonathan.a.grossberg{at}emory.edu

    Abstract

    Background Congress enacted the No Surprises Act (NSA) in 2021. The NSA relies on the ability for providers to appeal their out-of-network (OON) payment through an arbitration process known as Independent Dispute Resolution (IDR). This study was designed to evaluate the effective access to IDR for mechanical thrombectomy (MT).

    Methods This study uses a simulation to model the likelihood that neurointerventionalists have financially viable access to the NSA IDR process to seek adequate payment for MT OON claims.

    Results When evaluating professional claims, for only batches of four or more claims, would the expected payment recovery exceed the expected IDR costs. For global claims (both professional and technical components), a batch size of two claims would be required for the expected payment recovery to exceed expected IDR costs.

    For the 1000 simulations at large MT centers (300 MT annually), there were no instances where it would have been financially viable to submit professional-only OON claims to the IDR process. For global claims, it would have been financially viable to submit to IDR for only 13.2% of these claims. For smaller stroke centers, there were also no instances where it would have been financially viable to submit professional-only claims. For global claims, it would have been financially viable for only 3.3–6.1% of claims.

    Conclusions The NSA process was designed to protect patients from unexpected bills following non-elective medical services. Given the emergent nature of many neuroendovascular cases and the lack of access to the IDR process as this model illustrates, the field is at risk for under-reimbursement due to NSA legislation.

    • Political
    • Thrombectomy

    Data availability statement

    All data relevant to the study are included in the article or uploaded as supplementary information.

    https://doi.org/10.1136/jnis-2024-022202

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      Data availability statement

      All data relevant to the study are included in the article or uploaded as supplementary information.

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      Footnotes

      • X @JAGrossbergMD, @docroc99

      • JAG and EWC contributed equally.

      • Contributors Conception of Study: JAG, EWC, JAH; acquisition, analysis of data: EWC; interpretation of data for the work: all authors; drafting document: EWC, JAG; critically revising document: all authors; final approval: all authors. JAG: Guarantor for study.

      • Funding This work was supported in part by a grant from the Harvey L. Neiman Health Policy Institute.

      • Competing interests JAG: consulting - Cognition, Imperative; grant support EMCF, GRA, DOD, Emory Neurosurgery Catalyst; relevant volunteer position: Audit Chair, SNIS Board of Directors. JMM: Imperative Care – Consulting, Trial Steering Committee, Microvention – Consulting, Optimize Neurovascular – Scientific Advisory Board, relevant volunteer position – JNIS Associate Editor. GD: consultant for Medtronic, Microvention, Stryker, Cerenovus, Penumbra, Phenox, Route 92; relevant volunteer position – Vice President, SNIS Board of Directors. REH: Partner in Radiology Partners. JAH: Medtronic, Relievant, Sanofi—consulting, Balt, Rapid Medical—DMC Chair, Relevant volunteer positions-JNIS Deputy Editor, SNIS Chair Health Policy Committee.

      • Provenance and peer review Not commissioned; externally peer reviewed.

      • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.