Radiology Partners scores No Surprises Act wins at 600% of ‘qualifying payment amount’
Radiology Partners has “significantly outmatched other provider groups” via the No Surprises Act, scoring wins at more than 600% of the initial “qualifying payment amount” offer, according to new research.
The Centers for Medicare & Medicaid Services recently released NSA data from the first half of 2024. As Radiology Business reported previously, industry giant Rad Partners was the No. 1 initiator of these disputes tied to out-of-network healthcare services, with 136,784 between January and July. Georgetown University researchers recently took a closer look at the data, publishing their findings June 11 in Health Affairs.
They highlighted RP’s significant payment wins via the “independent dispute resolution” (IDR) process in 2024. In Q1, the practice earned a median prevailing offer at 631% of the qualifying payment amount—essentially, the median contracted rate for a service in the same geographic region. These wins continued in Q2, with a median at 610% of QPA.
“These high numbers highlight the disconnect between the two sides as they debate what constitutes a reasonable payment for [out-of-network] services,” Jack Hoadley, PhD, research professor emeritus with Georgetown’s Center on Health Insurance Reforms, and co-authors explained. “Providers believe the high volume of IDR disputes reflects inadequate payment by plans, exacerbated by possible manipulation of the [qualifying payment amount]. Plans respond that their QPAs are accurate and that providers should be willing to accept payments that align closely with in-network rates.”
Radiology and emergency services were the two specialties with the highest volume of resolved cases, accounting for about two-thirds of all determinations, the authors reported. For emergency services in the first half of 2024, the median prevailing offer was about 257% of QPA, a 30-percentage-point uptick from the end of 2023. Radiology saw a similar increase, with a median prevailing offer at 600% of QPA, up 40 percentage points from the end of 2023.
“These specialties are closely correlated to certain provider groups. For example, Radiology Partners accounts for nearly all of radiology cases, while Team Health, SCP Health, and Envision represent well over half of all emergency cases,” the authors noted.
Neurology and surgery won much higher awards than radiology and emergency medicine, albeit through a much smaller volume (about 9% of resolved cases in 2024). In Q1, the median prevailing offer for neurology was 1,222% of QPA and 1,178% in Q2. Meanwhile, in surgery, the median prevailing party offer was 1,818% of QPA in Q1 and 1,716% in Q2.
Providers were most successful in states such as Texas, Florida, Arizona and Virginia, with win rates between 89% and 91% in the first quarter, the authors noted. This was somewhat attributable to “high concentrations of the provider organizations that most frequently used IDR.” For instance, more than half of cases in Texas involved Radiology Partners-affiliated providers.
Activity levels of top initiators including Rad Partners, Team Health, SCP Health and AGS Health remained “relatively stable” between 2023 and 2024. However, HaloMD has emerged as a “frequent participant” in IDR cases. In 2023, the company accounted only for about 1% of resolved disputes, which climbed to 10% by Q1 of 2024. HaloMD was created to be the “leading provider of IDR services,” the authors noted, illustrating the rise of “profit enhancing middlemen” focused on these disputes.
“Whereas large provider organizations like Radiology Partners and Team Health have the internal resources to manage disputes on behalf of their providers, HaloMD and other third-party organizations can take on the administrative burden for smaller providers and offer them a greater opportunity to engage in IDR,” Hoadley and co-authors wrote. “As a provider group familiar with the IDR process wrote in a previous Forefront piece, ‘smaller practices have less ability to access IDR than do larger, well-capitalized organizations.’ This trend might be changing with the rise of IDR-specific middlemen.”
Along with concerns around these middlemen and the high concentration of disputes among private equity-backed players such as Rad Partners, the authors raised another concern. Will the long-term ramifications from these IDR decisions lead to higher healthcare costs and plan premiums?
“The issue remains whether the law’s mechanism for establishing a reasonable payment from plans to providers is working,” the authors concluded. “To the extent it is not, a key question is whether there are cost implications for the healthcare system as a whole and for consumers in particular.”
Update, June 20: Radiology Partners offered the following statement in response to the Health Affairs study:
- Neutral, value-based decisions: IDR decisions are made by independent, third-party entities that select the payment offer they believe most accurately reflects the value of the service. When the radiologist’s offer prevails, it’s because the arbitrator determined it best represents fair compensation for the care provided.
- Percentages of QPA for radiology services: Radiology services often have lower-dollar claims compared to other specialties, and as the departments explained, “low-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.”
- Limitations of the QPA as a benchmark: The QPA is not a reliable proxy for typical in-network rates. As noted in a Health Affairs article cited by Hoadley, “while the QPA was intended to be a representative (median) specialty-specific, in-network rate, the calculation methodology frequently results in values that are well below a typical market-based rate.”
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.