Medical societies representing radiology, emergency medicine and anesthesiology on Monday blasted new guidance from the Centers for Medicare & Medicaid Services related to the No Surprises Act.

CMS revealed the new details on Oct. 6 the same day it partially relaunched the independent dispute resolution process for settling disagreements between payers and providers over out-of-network payments. The federal government has indicated that it is not issuing directions on how health plans should calculate the “qualifying payment amount,” which is the key starting point of such disputes. Instead, insurers will have discretion to determine this figure via their own good-faith interpretation of recent court rulings and remaining regulations.

“Our organizations are strongly opposed to this newest guidance, which further broadens the already significant discretion health plans had on how they may calculate qualifying payment amounts under the NSA’s original implementation,” the Radiology Business Management Association, American College of Radiology, American Society of Anesthesiologists, American College of Emergency Physicians and Emergency Department Practice Management Association said in a joint statement issued Oct. 9.  

RBMA et al. also took issue with plans from the federal departments of HHS, Treasury and Labor to provide limited oversight of insurers in calculating the qualifying payment amount until at least May 1, 2024, and potentially Nov. 1 of next year. A Texas judge ruled in August that the methodology insurers use to calculate the QPA is tilted in their own favor, disallowing several provisions that go into this determination. The medical groups want the federal government to incorporate this court ruling into their guidance and prevent payers from slanting the IDR process in one direction.

“Our organizations are very concerned about this delay in full enforcement,” the medical societies wrote. “There is already lax enforcement of insurer compliance with the NSA’s requirements, including the fact that many plans are seemingly being allowed to delay payment to physicians (or simply not pay at all) following an independent dispute resolution ruling, without any consequences imposed by the departments. This newest announcement providing insurers with significant enforcement relief on the QPA further erodes the critical foundations Congress built into the NSA when it passed these important consumer protections into law and seems contrary to the federal court order which stated that this could be done expeditiously.”

RBMA, ACR and the others are urging the departments to “immediately reconsider” this decision and “promptly” issue specific guidance on how health plans should calculate the QPA. They’re also “discouraged” that, despite the relaunch of IDR on Oct. 6, the ability to batch together similar payment disputes remains “in a holding pattern” after recent court rulings.

“Without any improved guidance on batching, the administrative efficiencies that come from being able to batch disputes will not be realized, thereby increasing costs for physician practices, while causing the current backlog of unresolved disputes to continue to grow,” the statement closed. “We urge the departments to quickly reopen the portal to batched determinations, and concurrently provide effective guidance to all affected parties.”

You can find the full statement on the American College of Emergency Physicians’ website here, and read previous coverage about the NSA at the links below.