‘Extremely disappointed’: Biden administration gives payers more time to comply with No Surprises Act shakeup
The Biden administration issued new guidance May 1, granting payers more time to comply with changes to the No Surprises Act. Radiology groups are not happy about it.
In August, a judge ruled that the methodology health insurers use to calculate the “qualifying payment amount”—the basis for negotiation over out-of-network reimbursement—is unfairly tilted in their favor. The ruling was brought about by a lawsuit from the Texas Medical Association et al., challenging how the administration has implemented the landmark law.
Payers were slated to stop using the old qualifying payment approach on May 1. However, the departments of HHS, Labor and Treasury are now giving them an additional six months to comply, until Nov. 1, responding to feedback from the field.
“Despite taking reasonable steps to come into compliance, plans and issuers need additional time to complete the significant efforts associated with recalculating QPAs in a manner consistent with the statutes and regulations that remain in effect after the [TMA lawsuit],” the new guidance document states, adding that several changes require payers to manually locate data. “Therefore, the departments and [the Office of Personnel Management] consider it appropriate to extend the enforcement relief.”
Experts said health insurers were supposed to be using a median rate as a basis for negotiations under the No Surprises Act’s arbitration process. However, the QPA they actually used was often much lower, placing radiologists and other providers at a disadvantage in negotiations.
“We are extremely disappointed the departments have made the decision to continue using a flawed and legally invalidated system to the detriment of providers and ultimately the patients they serve,” Kit Crancer, chair of the Radiology Business Management Association’s Radiology Patient Action Network, said by email Thursday. “The execution of the No Surprises Act has disproportionately and negatively impacted radiology providers and must be revisited by Congress to ensure the law’s original intent is followed. As in the law’s original passage in 2020, we look forward to providing data highlighting current surprise coverage gaps, problems with implementation and potential solutions to policymakers.”
Jeffrey Davis, health policy director for McDermott+Consulting, shared news of the enforcement delay on Wednesday, calling it a “big win for health plans.”
“This is a big deal since health plans are still allowed to calculate QPAs basically however they want with little oversight from the federal government,” he added in a separate social media post. “QPA calculations are a BLACK BOX!”
Meanwhile, the administration on May 1 also released a new approach for resubmitting NSA disputes that were improperly batched, the American Hospital Association reported. The aim is to streamline the independent dispute-resolution process while enhancing user experience.
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.