Radiology accounts for the 2nd most IDR payment determinations under the No Surprises Act

Radiology accounted for the second highest number of payment determinations under the No Surprises Act in the back half of 2023, according to new data from the federal government released Thursday.

Between July 1 and the end of last year, parties initiated more than 390,000 disputes through the federal independent-dispute resolution portal. That represents a 35% uptick compared to the front half of 2023 and is “particularly notable” given that the feds halted the process for nine weeks after several court orders.

Arbitrators in these disputes between health insurers and providers rendered payment determinations across over 125,000 disputes in the second half of 2023. Emergency medicine services accounted for the majority at 59%, followed by radiology at 14%, figures similar to those recorded in early 2023. The number of determinations represents a 50% uptick when compared to the nearly 84,000 decisions made in the first half of last year.

“Despite the increase in the number of payment determinations, due to the high volume of disputes initiated, there are disputing parties who are still awaiting payment determinations,” the report noted. “The departments’ objective is to help certified IDR entities and disputing parties obtain resolution on disputes as expeditiously as possible.”

The top 10 initiating parties accounted for 76% of all disputes. These included large practice management companies, medical groups or revenue cycle management firms representing “hundreds” of providers, practices or facilities. Team Health, SCP Health and Radiology Partners were the top three initiating parties representing “thousands” of providers in multiple states and about 58% of all disputes. Rad Partners initiated 22,669 (or 7% of all) disputes, just ahead of multispecialty radiology provider Envision Healthcare with 19,225 (6%).

The prevailing offer was higher than the qualifying payment amount in about 88% of payment determinations, CMS reported. Prevailing offer amounts relative to the QPA varied by specialty and cost of the service. In radiology, the median prevailing offer was about 559% of the QPA. Other specialties such as surgery (967%) and neurology (1,262%) saw even higher differences.

“The departments [of HHS, Labor and Treasury] note that smaller-dollar items and services had higher prevailing offers expressed as a percent of the QPA, partly because a small dollar difference translates into a large percentage difference,” the report noted. “Given that providers, facilities, or provider of air ambulance service providers prevailed in the majority (82%) [up from 71% in H1 2023] of payment determinations during this period, the median prevailing offer is often the offer from the provider, facility or provider of air ambulance services.”

Healthcare consultant Jeffrey Davis commented on the report Thursday, contending that the wide gaps may signal “the QPA itself may be artificially low, as most independent arbiters are siding with providers.”

“It makes sense that providers are pursuing the IDR process if the QPAs are unreasonably low and do not reflect market rates,” Davis, who is health policy director at McDermott+Consulting, wrote on social media June 13. “The fact that the median prevailing offers as a percentage of the QPA are all over the map also demonstrates that the QPA is an unreliable number that is not a meaningful representation of an appropriate payment rate.”

You can find the full report from CMS here.  

Marty Stempniak

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. 

Trimed Popup
Trimed Popup