No surprises law’s QPA calculation challenged for violation in new study

According to a study, insurers can calculate median in-network rates for specialty services using contracted rates for services that have never been negotiated.

In unsurprisingly possible violation of the law, health insurance companies’ calculations of qualified payment amounts (QPAs) for anesthesiology, emergency medicine, and radiology services likely include provider contract rates. primary (PCP), a new study says.

The study conducted by Avalere Health and commissioned by three national physician organizations examined a subpopulation of general practitioners and determined that contracting practices can have a direct impact on DPA.

“Despite the law’s directive that the calculation of APQ be based on payment data for the ‘same or similar specialty’ in the same geographic region, insurers may calculate median rates in the network for specialty services using PCP contract rates for services that were never negotiated, may never be provided by these physicians, and may never be paid,” the study states.

This method may violate the No Surprises Act and produce insurer-calculated QPAs that do not represent typical payments for these services, according to the study.

In the study, 75 employees of primary care practices who play a role in contracting with insurers were asked whether they sign contracts with insurers for services they rarely or never provide, as well as as on the trading practices related to these services.

68% of respondents had services they rarely provide (less than twice a year) included in their contracts, and 57% of respondents had services they never provide included in their contract, according to the survey.

“This new research raises important questions about the accuracy of QPAs calculated by insurers,” said American Society of Anesthesiologists President Randall M. Clark, MD, FASA. “We have received reports of extremely low QPAs that bear no resemblance to actual network rates in the geographic area; yet these same rates are used by insurers as an upfront payment.”

The American Society of Anesthesiologists, the American College of Emergency Physicians, and the American College of Radiology call on policy makers to eliminate PDA as the primary adjudicating factor and ensure the integrity of PDA insisting that they should be calculated on the basis of “same or similar specialty tariffs in the network.

This would mitigate “the unintended consequences of health insurers’ reliance on in-network median rates based in part on data from providers who do not actively negotiate those rates,” said Gillian Schmitz, MD, FACEP, president of the American College of Emergency Physicians. . “Doctors rely on fair reimbursement to keep their doors open and continue to provide life-saving medical care to their patients.”

Amanda Norris is Revenue Cycle Writer for HealthLeaders.

Denise W. Whigham