Insurers fudging payment estimates for radiology services under No Surprises Act
New research claims commercial insurers are fudging payment estimates for radiology and other services under the No Surprises Act.
The landmark law first took effect in 2022, establishing a process for physicians and insurers to settle disputes over out-of-network care. A key point for starting negotiations is the “qualifying payment amount,” essentially the median contracted rate for similar such services in a geographic area.
However, a new analysis claims the “benchmark” QPA payers calculate often “dramatically” understates the actual median in-network rates insurers are paying for in-network care.
"Our clinicians are fiercely supportive of the patient protections afforded under the [No Surprises Act], but we continue to see insurers undermine the law,” Eric Berger, executive director of Americans for Fair Health Care, a national coalition of over 70,000 physicians “fighting insurer abuse,” which commissioned the study, said in a statement Dec. 18. “Using inaccurate [qualifying payment amounts] drives use of the NSA's arbitration process and adds cost to the healthcare system,” he added.
There were almost 4 million payment disputes resolved through the No Surprises Act’s independent dispute resolution process between mid-2022 and the end of the 2024. To narrow the analysis, researchers focused on a single quarter of data, logged in the final three months of 2024. They further narrowed the study’s scope to only the most common insurers—Aetna, Blue Cross Blue Shield, Cigna and UnitedHealthcare—which collectively represent 77% of disputes during this period.
Researchers with Washington-based consulting firm NDP Analytics also homed in on eight of the most common services subject to No Surprises Act disputes. These included CT angiography of the head or neck, MRI of the brain, and CT of the abdomen and pelvis, along with multiple emergency services. In about 65% of disputes subject to the independent dispute resolution process, the reported qualifying payment amount was lower than the actual median in-network contracted amount, the study found.
For Aetna, in 3 of the 4 radiology CPT (Current Procedural Terminology) codes, median in-network contracted rates were higher than reported qualifying payment amounts in all metropolitan statistical areas (and in 90% of the MSAs for the fourth code). Same for Cigna in 3 of 4 codes, and in almost 80% of metro areas for the 4th imaging code.
“The No Surprises Act was designed to ensure fairness in out-of-network payment disputes. Instead, the statutory benchmark—calculated unilaterally by insurers and shielded from rigorous review—has distorted the entire process,” Americans for Fair Health Care said in its announcement. “Unfortunately, [Centers for Medicare & Medicaid Services] oversight remains minimal. Despite a statutory requirement for federal monitoring of QPA calculation and a promised 2025 report to Congress, CMS has released only one QPA audit since the NSA took effect in 2022.”
The report is the latest in a tit-or-tat between insurers and providers, releasing dueling reports detailing what’s wrong with the No Surprises Act. Previously, AHIP, the country’s largest health insurance lobbying group, released its own such analysis in October. It found that nearly 40% of healthcare providers’ surprise billing disputes were ineligible for the dispute-resolution process, with many still advancing through arbitration. Industry giant Radiology Partners is the heaviest user of the IDR process, initiating 136,784 disputes between January and July of last year, another analysis found. RP significantly outmatched other provider groups, scoring wins at over 600% of the initial QPA offer.
Members of Americans for Fair Health Care include ApolloMD, Envision Healthcare, Houston Radiology Associated, Quantum Radiology, Radiology of Indiana, Rad Partners, Radix, Revenue Cycle Coding Strategies, SCP Health, TeamHealth, and NSPC Brain & Spine Surgery.
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.