CMS Chief Hears Radiology Concerns About NSA Dispute Process

ACR^® recently participated in a meeting with Rebekah Armstrong, Chief of Staff for CMS Administrator Mehmet Oz, MD. The meeting, organized by Zotec Partners¹ and Strategic Radiology², focused on sharing real-world practice experiences with insurance carriers since the enactment of the No Surprises Act (NSA).

Radiology practices around the country have been forced to accept stagnant and/or lowered in-network contract rates or face going out-of-network and using the federal Independent Dispute Resolution (IDR) process to negotiate reasonable reimbursement rates. Radiologists are vindicated in demonstrating providers are not the problem, evidenced by court decisions, disputed claims arbitration results, and insurers’ stronghanded actions that force radiologists out of their networks.

During the meeting with Armstrong, Radiology Associates of North Texas, a member of Strategic Radiology and one of the largest independent, physician-owned radiology practices in the U.S., shared its experience with contract negotiations and the IDR process. One large payer in Texas has continually refused to negotiate adequate in-network contract rates, forcing the practice out of network. In the IDR process, the payer consistently declines to make reasonable market-based offers that reflect inflation or actual contracting conditions. At the same time, even when providers prevail in IDR, the process is not being honored with payers frequently failing to comply with the statutory requirement to pay awards within 30 calendar days.

At the center of the issue is the Qualifying Payment Amount (QPA), which is intended to represent the median in-network rate for services as of 2019, adjusted annually for inflation. In practice, that benchmark is increasingly disconnected from market reality. When a benchmark drifts below the market it is intended to represent, the system cannot function as designed. The Fifth Circuit Court of Appeals recently ruled that key aspects of the federal QPA calculation methodology are unlawful, finding that the inclusion of certain non-negotiated rates resulted in artificially low rates.

Payers argued high provider success rates in the IDR process may be driving unintended cost increases. In reality, IDR volume and provider success rates are being driven by payers’ refusal to negotiate reasonable in-network rates, meaningfully participate in open negotiations, or adjust IDR offers despite a consistent pattern of physicians prevailing.

Armstrong acknowledged limitations in CMS’ ability to enforce compliance and impose penalties on carriers under the NSA, but indicated it is a high-priority issue for the agency. She appreciated hearing the provider perspective and firsthand experiences.

If you have questions or for more information, contact Katie Keysor, ACR Vice President, Economic Policy.

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¹Zotec provides end-to-end revenue cycle management services to many independent physician networks across the country. Founded in 1998, Zotec has assisted over 30,000 providers and managed over $8 billion in client collections.

²Strategic Radiology is a coalition of privately owned independent, local radiology practices that have come together to improve quality, gain operational efficiencies, and innovate the future of radiology's private practice model: It is 100% owned by radiologist member shareholders.