July 08, 2021

Federal Regulations on Surprise Billing Raise Red Flags for ACR

The U.S. Departments of Health and Human Services (HHS), Labor and Treasury, along with the U.S. Office of Personnel Management, released the first of several interim final rules with comment (IFC) July 1 to implement the No Surprises Act. The act was part of the Consolidated Appropriations Act, 2021 and is scheduled to take effect Jan. 1. The law represents a significant step forward for patients and providers.

This first rule addresses requirements related to patient cost sharing for emergency services, air ambulance services provided by out-of-network providers and non-emergency services provided by out-of-network providers at in-network facilities in certain circumstances.

In addition, this IFC provides detailed information about the methodology for calculating the “qualifying payment amount” (QPA). In recent comments to HHS Secretary Becerra, the American College of Radiology® (ACR®) provided input about calculation of the QPA to ensure fairness to healthcare providers. The ACR is disappointed with some aspects of the QPA calculation methodology, including the treatment of each provider contract equally regardless of the practice size and market share of the providers when determining the median rate. For example, the contracted rate of a practice with 25 radiologists serving 80% of the market is treated the same as contracts with three radiologists serving 5% of the market. The rule also indicates that incentive-based payments including bonuses and risk sharing is excluded from calculation of median rates.

The IFC does not address the ACR-supported independent dispute resolution process designed to allow providers and insurers an avenue to resolve disputes about out-of-network rates. However, this process is mandated by law and will be addressed in a future rule.

The ACR has prepared a detailed summary of the interim final rule and will submit comments by the Sept. 7 deadline.

Questions about the No Surprises Act Interim Final Rule should be directed to Katie Keysor, ACR Senior Director of Economic Policy.