# No Surprises Act Independent Dispute Resolution Outcomes for Air Ambulances

## TL;DR

A study analyzed air ambulance payment disputes in 2023 under the No Surprises Act, finding that air ambulance companies won most cases and requested higher payments than insurers.

## Contribution

The study provides the first detailed analysis of air ambulance dispute resolution outcomes under the No Surprises Act in 2023.

## Key findings

- Air ambulance organizations won 86.4% of disputes, with private equity-backed organizations involved in 61.3% of cases.
- Winning offers averaged $32,463, significantly higher than insurers' median contracted rates.
- Only 48.4% of cases had full financial data, limiting comprehensive analysis.

## Abstract

What were the outcomes of air ambulance cases processed by the No Surprises Act’s independent dispute resolution entities in 2023?

In this cross-sectional study of 5678 cases, arbiters decided in favor of air ambulance organizations in 86.4% of the disputes against insurers, and 61.3% of cases involved a private equity–backed organization. Financial measures were reported for only 48.4% cases; among them, the mean qualifying payment amount (a measure of the insurer’s median contracted rate) and winning offers were $15 561 and $32 463, respectively.

These findings suggest that more complete public data on air ambulance independent dispute resolution cases is needed to monitor the impacts of the No Surprises Act.

This cross-sectional study describes independent dispute resolution cases arbitrated in 2023 for fixed and rotary wing air ambulance services following the No Surprises Act.

The No Surprises Act (NSA) banned surprise patient balance bills and established a binding arbitration system to resolve payment disputes between insurers and health care providers (eg, clinicians, hospitals, air ambulance organizations) for certain services, including air ambulance transportation. Understanding use and results of this new independent dispute resolution (IDR) system can inform ongoing adjustments to its implementation.

To describe the involved parties and outcomes of air ambulance NSA IDR cases.

This cross-sectional study assessed cases arbitrated through NSA IDR in 2023 as reported by the Centers for Medicare & Medicaid Services. Participants included air ambulance organizations and commercial insurers. Data were analyzed between August 1 and September 1, 2024.

Fixed-wing and rotary transport disputes arbitrated under the NSA IDR system.

The activation components of fixed-wing and rotary transport disputes were evaluated with data from 2 distinct public files: (1) disclosed parties and outcomes relative to qualifying payment amounts (QPAs), the insurers’ median of contracted rates for similar services in the region among similar health plans; and (2) monetary measures but without parties. The first file describes the insurers and organizations involved, including their ownership status, as well as the prevailing party and the offers and decisions relative to QPA. The second file describes QPAs, offers, and decisions monetarily and these are compared with Medicare’s urban allowed amount.

There were 5678 IDR cases in 2023, comprising disputes for 4935 rotary and 743 fixed-wing transports. Air ambulance organizations offered a mean (SD) of 3.18 (4.20) times QPA, and insurers offered 1.39 (3.89) times QPA. Organizations won 4905 cases (86.4%) at a mean (SD) of 2.95 (4.12) times the QPA. A total of 3478 cases (61.3%) involved organizations owned by private equity investors, and these cases had higher prevailing offers relative to the QPA. Due to data suppression, analysis of financial measures was possible for 2897 of 5983 activation cases (48.4%), among which the mean (SD) QPA offer was $15 561.08 ($9730.97) (3.74 [2.31] times Medicare), and the winning offer was $32 463.70 ($9987.17) (7.82 [2.39] times Medicare).

In this cross-sectional study of air ambulance payment disputes, air ambulance organizations won most cases, requiring insurers to pay more in these cases. Notably, the NSA does not require changes to patient cost-sharing based on IDR outcomes. Assessment of the financial metrics and outcomes of air ambulance cases was limited due to missing and masked information. Continued monitoring of air ambulance IDR cases is needed to assess the impacts of the NSA.