John
Looking at an EOB, it should be obvious that the payor considers the claim to be subject to the balance billing protections of the No Surprises Act (i.e. emergency service by nonpar provider, service at in network facility by nonpar provider, etc.). According to the first IFR, payors have to provide the following with their initial payment/denial:
- The Qualifying Payment Amount (QPA) for each service
- A statement certifying that the QPA applies for purposes of the recognized amount (i.e. the allowed amount used to process the claim).
- A statement that if the provider wishes to initiate a 30-day open negotiation period, the provider may contact the payor to do so, and that if the 30 day negotiation period does not result in a determination, the provider may initiate the independent dispute resolution process within 4 days after the end of the 30 day negotiation period
- Contact information for the appropriate office to initiate negotiations
I believe the above might not hold true if the claim is processed in accordance with a state law or All Payor Model Agreement that is more favorable to the patient, but I haven't reviewed the rules with that scenario in mind.
I don't believe you can appeal to the IDR until you complete the open negotiation, and it has to be done within that 4 business day window after the 30 business day open negotiation period closes.
I'm sure you will never accidentally appeal to the IDR, and I suspect most radiology groups will very rarely or never appeal to the IDR, since you can only do one CPT code per IDR appeal for a 30 day period per appeal, and the loser pays the IDR fee (likely to be $100's). I can't see appealing to the IDR unless it's a big payor and a high volume high dollar code where I'm sure I can make a good case for a rate higher than the QPA. I can really only see it happening in the context of a contentious contract negotiation with a major payor.
The QPA is defined as (paraphrased), the median contracted rate for the same payor in the same market (i.e. group, individual, etc.) in the same geographic area, as of January 2019, adjusted for inflation based on the CPI-U (last time I checked, that was +9%).
As currently laid out in the IFRs, you will have to rely on the EOB from the payor to know the QPA, and there isn't any way to check their calculation. As of right now, there isn't an avenue for appeal of a QPA calculation, other than perhaps going to court. One of the things RBMA has asked for in comments is transparency around the calculation, or some kind of audit process.
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David Smith FACMPE
Executive Director
United Imaging Consultants
Mission KS
(785) 393-8387
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Original Message:
Sent: 11-09-2021 15:48
From: John Pugh
Subject: No Surprises Act
Here are a couple of questions that have come up in connection with the No Surprises Act, perhaps the wisdom of the forum can assist with answering:
- Sometimes a claim is submitted to a carrier we believe to be out-of-network but it ends up being processed by a TPA as in-network. Is there any penalty under the No Surprises Act if we accidentally appeal such a claim without realizing its correctly processed?
- Will there be a published source for determining the Qualifying Payment Amount? If so, where and when will it be available?
Thanks!
John
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John E. Pugh
Pugh Healthcare Business Advisors
P: 609.644.4479 F: 609.503.2476