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In possible violation of the No Surprises Act, health insurance company calculations of Qualified Payment Amounts for anesthesiology, emergency medicine and radiology services – and possibly other specialty services – likely include rates from primary care provider contracts.
That’s according to a new study conducted by Avalere Health and commissioned by three national physician organizations. It examined a subpopulation of PCPs and determined that contracting practices may directly impact the QPA.
Despite the law’s directive that QPA calculation be based on payment data from the “same or similar specialty” in the same geographic region, insurers may be calculating median in-network rates for specialty services using PCP contracted rates for services that were never negotiated, may never be provided by those physicians and may never be paid, according to the report. This method likely violates the law and produces insurer-calculated QPAs that don’t represent typical payments for those services, it said.
Insurers have already attempted to use the new law to raise profits by artificially lowering the QPA, the analysis showed. And they’ve canceled the contracts of providers which have declined large reimbursement cuts. Using such erroneous data in QPA calculation may further narrow medical networks, deny patients their choice of providers and could delay diagnosis and treatment of illness and injury, the authors said.
WHAT’S THE IMPACT
The research raises questions about the accuracy of insurer-calculated QPAs. Some extremely low QPAs bear little to no resemblance to the actual in-network rates in a given geographic area, yet those rates are being used by insurers as their initial payment.
In the study, 75 primary care practice employees who have a role in contracting with insurers were surveyed regarding whether they contract with insurers for services they rarely or never provide, as well as negotiation practices related to these services. The survey found that 68% of respondents had services they rarely provide – fewer than twice a year – included in their contracts, and 57% of respondents had services they never provide included in their contract.
Congress debated including a benchmark for determining payment rates for out-of-network providers in the No Surprises Act but decided not to dictate a specific rate. Such a rate, Congress argued, could not adequately reflect the different specialties and regions in which care is provided across the country.
Instead, the law directed insurance companies to calculate their own QPAs and directed independent arbiters to take them into consideration when settling payment disputes. The QPA is intended to reflect a health insurer’s median contracted rate to providers based on the region in which they practice and for providers in the “same or similar specialty.”
But insurance companies may be incorporating contracted rates for services like those included in the PCP contracts that will never be provided by those physicians, and for which insurers will never pay, according to the report. And the inclusion of rates not actively negotiated by such providers would likely artificially lower the QPA, effectively reducing payments for the anesthesiologists, emergency physicians and radiologists, who actually do provide those services.
Authors called on policymakers to eliminate the QPA as the sole or primary factor in arbitration, saying they should be calculated based on “same or similar specialty” in network rates. This, they said, would mitigate the unintended consequences of relying on insurers’ median in-network rates, which are based in part on data from providers who don’t actively negotiate those rates.
THE LARGER TREND
The No Surprises Act appears to be working as intended, according to a May survey by AHIP and the Blue Cross Blue Shield Association. The survey shows that the law, which was passed with the intent of preventing surprise medical bills, has lived up to that goal by preventing more than two million surprise medical bills across all commercially insured patients.
The analysis also found that, if the trend continues, more than 12 million surprise bills will be avoided in 2022.
ON THE RECORD
“This study demonstrates yet another reason why policymakers cannot make the QPA the primary factor in such arbitration nor base important regulations solely on insurer-produced and defined data,” said Dr. Jacqueline Bello, chair of the American College of Radiology Board of Chancellors. “Decision makers should work with healthcare providers and insurers to consider relevant and verifiable data, ensure that patients have adequate provider networks, and protect access to care by ensuring sensible, sustainable reimbursement.”
Twitter: @JELagasse
Email the writer: [email protected]