As EDPMA continues its advocacy efforts, including urging the relevant federal agencies to provide additional guidance and resources to assist practices with the No Surprises Act, the Center for Consumer Information and Insurance Oversight (CCIIO) recently issued several new resources that EDPMA members may find useful navigating the rules and requirements.
- New Frequently Asked Questions (FAQs): On Friday, August 19th, 2022, CCIIO released new FAQs, which can be accessed via this link. In addition to other helpful information, in these FAQs, CCIIO has addressed a key concern expressed by EDPMA in its advocacy efforts. Under the guidance regarding “Methodology for Calculating Qualifying Payment Amounts,” CCIIO states,
The Departments have been informed that some plans and issuers establish contracted rates by offering most providers the same fee schedule for all covered services, and then it is up to the providers to negotiate increases to the rates for the services that they are most likely to bill. After the negotiation process, the entire fee schedule may be included in the provider contract, with contracted rate modifications made only to certain service codes based on the negotiations. For example, an anesthesiologist’s contract may include rates for anesthesia services that are a result of negotiations between the plan or issuer and the provider and that are materially different from the contracted rates the plan or issuer has for the same anesthesia services with other providers in specialties that do not bill for those services. Similarly, an anesthesiologist’s contract may also include contracted rates for other services the anesthesiologist does not provide (for example, dermatology services) that are identical to the contracted rates the plan or issuer has with other providers in specialties who similarly do not bill for those services. (Footnote omitted).
To account for these “ghost rates” that could be skewing QPA calculations, CCIIO clearly states here that “if a plan or issuer has contracted rates that vary based on provider specialty for a service code, the median contracted rate (and consequently the QPA) must be calculated separately for each provider specialty, as applicable.” CCIIO is providing a 90-day health plan compliance window with this new clarification. For more details see the full discussion in FAQ #14.
CCIIO also reinforced health plan obligations to provide very specific information with the initial payment or denial of payment. CCIIO explicitly states, when providing a payment, a health plan that “includes only a general statement that the claim was processed according to applicable state or Federal law and directs the nonparticipating provider to a website for more information” would not meet the requirements for information that must be included with the initial payment or denial of payment. For more details see the full discussion in FAQ #19.
- Federal IDR Process Status Update: On August 19th, CCIIO announced, in conjunction with the other relevant federal agencies, a status update on Federal IDR. The document contains statistics on disputes in Federal IDR thus far. Of note, “Between April 15th and August 11th, disputing parties initiated over 46,000 disputes through the federal IDR portal, which is substantially more than the Departments initially estimated would be submitted for a full year,” but only 1,200 have resulted in a payment determination. Nearly half of the 46,000 initiated disputes have been challenged by the non-initiating party. The document states “The primary cause of delays in the processing of disputes is the complexity of determining whether disputes are eligible for the federal IDR process.” The full document can be accessed via this link.
- New Technical Assistance Document for Federal IDR Certified IDR Entities: CCIIO stated that it has issued new guidance for certified IDR entities in an effort to improve the federal IDR process, including further details on policies regarding the “batching” of claims for Federal IDR. Note that CCIIO provides guidance on process for claims that were inappropriately batched, but are otherwise eligible for Federal IDR. The guidance document states, “Certified IDR entities should direct the initiating party to resubmit the inappropriately batched or bundled qualified IDR items or services within four business days after the certified IDR entity notifies both parties of the inappropriately batched or bundled dispute and the steps for re-submitting the qualified IDR items or services (if they were otherwise eligible under the Federal IDR process timelines and rules) in accordance with the technical direction provided to certified IDR entities by the Departments. If the initiating party does not resubmit the qualified IDR items or services within four business days, the qualified IDR items and services cannot be considered for payment determinations.” The full updated guidance document can be accessed via this link.
- New “Specified State Law” Resource. CCIIO previously released a document to help stakeholders navigate states where only the Federal NSA provisions will apply compared with those states where both the NSA provisions and “Specified State Law” provisions could apply depending on the scope of the state law and the characteristics of the dispute. This week, CCIIO released an updated guidance document with similar information that has been enhanced to include hyperlinks to certain state resources.