No Surprises Act QPA Calculation Questioned for Violation in New Study

Insurers may be calculating median in-network rates for specialty services using contracted rates for services that were never negotiated, study says.

In possible violation of the No Surprises Act, health insurance company calculations of qualified payment amounts (QPA) for anesthesiology, emergency medicine, and radiology services likely include rates from primary care provider (PCP) contracts, a new study says.

The study conducted by Avalere Health and commissioned by three national physician organizations examined a subpopulation of PCPs and determined that contracting practices may directly impact the QPA.   

"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 study said.

This method may violate the No Surprises Act law and produce insurer-calculated QPAs that do not represent typical payments for these services, the study said.

In the study, 75 primary care practice employees who have a role in contracting with insurers were surveyed regarding whether they contract with insurers for services they rarely or never provide, as well as negotiation practices related to these services.

68% of respondents had services that they rarely provide (fewer than twice a year) included in their contracts, and 57% of respondents had services that they never provide included in their contract, the survey found.

"This new research raises significant questions about the accuracy of insurer calculated QPAs," said American Society of Anesthesiologists President Randall M. Clark, MD, FASA. "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."

The American Society of Anesthesiologists, the American College of Emergency Physicians, and the American College of Radiology are calling on policymakers to eliminate the QPA as the main factor in arbitration and ensure the integrity of the QPA by insisting they be calculated based on "same or similar specialty" in-network rates.

This would mitigate "the unintended consequences of relying on health insurers' median in-network rates based partially on data from providers who don’t actively negotiate those rates," said Gillian Schmitz, MD, FACEP, president of the American College of Emergency Physicians. "Physicians rely on fair reimbursement to keep their doors open and continue providing lifesaving medical care to their patients."