December 02, 2021

Let the ACR Know What Your Payers Are Doing About Surprise Billing

As the American College of Radiology® (ACR®) expected, insurers now are using the Biden administration’s misinterpretation of the No Surprises Act, passed to protect patients during insurer-provider payment disputes for out of network care, to narrow medical networks and restrict patients’ access to their current providers.

The College reported earlier this week that Blue Cross Blue Shield of North Carolina is the first insurer to tell providers they may be considered an “outlier contract” scheduled for “termination” if they don’t accept an immediate, drastic cut in reimbursement for services provided. The insurer says that the No Surprises Act allows them to take such action, citing the “Qualifying Payment Amount” as a “reasonable market rate.”

In comments to the Centers for Medicare and Medicaid Services (CMS) related to the first No Surprises Act interim final rule, the ACR focused on the flaws within the QPA calculation methodology. The College believes the methodology does not represent real-world median contracted rates. The primary issue with the calculation methodology is the treatment of a contract as a datapoint in the median calculation, rather than individual claims representing datapoints. CMS does not consider the number of claims or services provided under a contract. As a result, there is potential downward skewing of the QPA calculation.

The No Surprises Act stated that the QPA should be one of many equally weighted factors considered during payment disputes. However, the second interim final rule issued in October by CMS ignored the law’s intent and made the QPA the primary factor in independent dispute resolution arbitration.

The ACR seeks member input to determine how widespread attempts are by insurers to narrow physician networks. Members who receive letters from insurance companies threatening contract termination are asked to contact Katie Keysor, ACR Senior Director of Economic Policy. If providing letters to the ACR, please ensure that any specific fee data is blocked out before sending.