Insurer benchmark used for NSA disputes lower than in-network rate

Qualifying payment amounts (QPAs) that insurers calculate under the No Surprises Act (NSA) often understate actual median in-network payment rates for practices, including radiology, suggests a report published December 18 by Americans for Fair Health Care (AFHC). 

Among the results, the AFHC found that reported QPAs were lower than the median in-network contracted amount in about 65% of disputes. And networking rates were on average 300% in these cases. 

“Our clinicians are fiercely supportive of the patient protections afforded under the NSA, but we continue to see insurers undermine the law,” said Eric Berger, AFHC’s executive director, in a prepared statement. “Using inaccurate QPAs drives use of the NSA’s arbitration process and adds cost to the health care system.” 

For claims that do get to independent dispute resolution (IDR), the NSA lists several criteria for neutral, third-party arbiters to consider when determining reimbursement for health services.  

The QPA, one of these criteria, is meant to be a median in-network rate of services in particular geographic regions. It is also used to determine patient cost sharing for items and services protected by the NSA. However, current litigation against federal departments administering the NSA challenges the validity of the QPA. 

The study, conducted by NDP Analytics on behalf of AFHC, matched publicly reported QPA values to median in-network contracted rates published by insurers for identical CPT codes and geographic regions. 

It featured the most common insurers and service types disputed. Insurers included Aetna, Blue Cross Blue Shield, Cigna, and UnitedHealthcare, while services included the following: CT angiography (CTA) of the head, CTA of the neck, brain MRIs, abdominal and pelvic CT exams, emergency department visits for evaluation and management, emergency department visits of high complexity, emergency department visits with a high level of medical decision-making, and critical care services in the first 30 to 74 minutes. 

The study also revealed reported QPAs of less than $20 in more than 60,000 disputes; nearly 1,000 instances of a reported QPA that was less than one dollar; and more than 20,000 instances of $0 offers, irrespective of the QPA. 

It outlined differences between individual insurers and current procedural terminology (CPT) codes for medical imaging-related services. For the most part, median in-network contracted rates were higher than reported QPAs in all metropolitan statistical areas. 

The results suggest that either the QPA method is inherently flawed or that QPAs are incorrectly calculated, the AFHC wrote, noting that governmental enforcement and oversight are important to address these concerns to “protect the integrity of the NSA.” This includes having the Centers for Medicare and Medicaid Services (CMS) prioritize alignment of the QPA calculation method with statute and end enforcement discretion.

“Since QPAs are calculated by insurers without transparency or oversight, regular audits with public reporting are not just statutorily mandated, they are necessary to ensure system integrity,” AFHC noted. “The departments must honor their oversight responsibilities that Congress established in the law.” 

Read the full report here.