ACR, other groups cry foul over insurers’ methods for calculating out-of-network payments
More than two-thirds of primary care professionals have contracts with insurers covering services, including advanced-imaging procedures, that they rarely if ever perform.
More than half the field contracts for services they don’t supply at all.
Frustratingly for radiology—along with anesthesiology, emergency medicine and likely other specialties—insurers have been using the primary-care rates to calculate national Qualifying Payment Amounts (QPAs) for out-of-network transactions.
More to the point, they’ve been factoring in the lowball prices to justify underpaying specialists for their expertise. They’re likely emboldened to do so by Congress’s decision to let insurers set their own out-of-network rates, albeit with dispute arbitration supplied by independent contractors.
‘Insurers Have Already Attempted to Use the No Surprises Act to Raise Profits by Artificially Lowering the QPA’
The dynamics are out in the open now thanks to a survey and analysis commissioned by the American Society of Anesthesiologists (ASA), American College of Emergency Physicians (ACEP) and American College of Radiology.
Flagging survey findings for public scrutiny, the ACR says insurers using primary-care rates to pay specialists may be doing so in violation of the No Surprises Act.
“Despite the law’s directive that QPA calculation be based on payment data from the ‘same or similar specialty’ in the same geographic region, insurers may be calculating median in-network rates for specialty services using PCP contracted rates for services that were never negotiated, may never be provided by those physicians and may never be paid,” the ACR states in a news release posted Aug. 17. “This method may violate the law and produce insurer-calculated QPAs that do not represent typical payments for these services.”
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Insurers have already attempted to use the new law to raise profits by artificially lowering the QPA. Further, they have cancelled contracts of providers who declined large reimbursement cuts. Using such erroneous data in QPA calculation may further narrow medical networks, deny patients their choice of providers and could delay diagnosis and treatment of illness and injury.”
‘An Inaccurate Representation of the Rates Commonly Paid’
According to the survey report, which was researched and prepared by Avalere Health, 68% of 75 responding primary-care practice representatives indicated they contract for services they provide fewer than twice a year.
A majority, 57%, said they contract for services they never provide.
The survey further showed that 59% of PCP offices contract for emergency services, 56% do so for advanced imaging and 23% for anesthesiology.
Summarizing the project’s key findings, the authors highlight three:
- Many primary care providers (PCPs), who significantly outnumber other specialties, are contracting with insurers for services the providers rarely or never provide.
- Most PCPs who rarely or never provide certain services do not actively negotiate payment rates for those services.
- The existence of PCP contracted rates for services rarely or never provided could cause the QPA to provide an inaccurate representation of the rates commonly paid for services rendered.
‘Policymakers Cannot Make the QPA the Primary Factor in Dispute Arbitration’
Reacting to the results, leaders of the three commissioning specialties allowed their tone to convey their determination to fight back:
ASA President Randall Clark, MD: “We have received reports of extremely low QPAs that bear absolutely no resemblance to actual in-network rates in the geographic area, yet these same rates are being used by insurers as their initial payment.”
ACEP President Gillian Schmitz, MD: “Physicians rely on fair reimbursement to keep their doors open and continue providing lifesaving medical care to their patients.”
ACR Board of Chancellors Chair Jacqueline Bello, MD: “This study demonstrates yet another reason why policymakers cannot make the QPA the primary factor in [dispute] arbitration nor base important regulations solely on insurer-produced and defined data. Decisionmakers should work with healthcare providers and insurers to consider relevant and verifiable data, ensure that patients have adequate provider networks and protect access to care by ensuring sensible, sustainable reimbursement.”
Read the full ACR news release here and the Avalere Health survey report here.
Dave P. has worked in journalism, marketing and public relations for more than 30 years, frequently concentrating on hospitals, healthcare technology and Catholic communications. He has also specialized in fundraising communications, ghostwriting for CEOs of local, national and global charities, nonprofits and foundations.