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  • 1.  Multiple Procedure Reductions on QPA's

    Posted 07-07-2023 10:01

    Can anyone point me to language in the regs or elsewhere that says payors paying out of network claims subject to the No Surprises Act balance billing limitations are allowed to adjust the QPA with multiple procedure reductions?  We're seeing Ambetter do this, but I can't find anything that says it's permitted. 

    I want to be sure I haven't missed something before I start rattling cages.

    Thanks

    Dave

     

     

           David Smith, FACMPE  |  Executive Director  |  913.444.9359

    5800 Foxridge Dr.  Ste 240  |  Mission, KS  66202  |  www.uickc.com

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  • 2.  RE: Multiple Procedure Reductions on QPA's

    Posted 07-10-2023 14:06

    My experience with Centene/Ambetter - they aren't the best at following rules.

    I had to file a complaint with the Georgia Commissioner of Insurance.  We have a Georgia No Surprise Billing Rule.  This rule points payers toward the Fair Health database for rates if they have never had a contract with a provider.  Ambetter didn't follow these rules and paid whatever they preferred.  The Fair Health database in my area is 205% Medicare.  Ambetter paid 105% during 2021 and 125% during 2022.  After I filed my complaint with Georgia, Ambetter did load and start paying the Fair Health rates.

    There's a class action suit against Ambetter.  It touches on a couple of things: (1)Ambetter does not have an adequate network and (2)Ambetter misleads former Medicaid members into believing Ambetter from Peach State (Peach State is their Medicaid product in GA) is a Medicaid product.  Issue number one means a lot of us will fall under NSA rules.

    If you don't see a multiple produced rule, I doubt there is one.  I've not heard it addressed in numerous CMS presentations.  If they are called out, my experience is you have to get the governing body involved to make Ambetter comply with the rules.  And I'm sure Ambetter will hope all those campaign contributions make a difference.

    Good luck......Chris



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    R. Christopher Sluder CPA
    Administrator
    Rome Radiology Group
    Rome GA
    (706) 291-2661
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    Original Message


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