QUESTION:
I think that I am beginning to understand the No Surprises Act (“NSA”). But try as I might, I still have trouble understanding how the amount that we will be paid if we provide care to a person covered by the NSA will be determined.
OUR ANSWER FROM HORTYSPRINGER ATTORNEY HENRY CASALE:
The Qualified Payment Amount (“QPA”) is the key to understanding the payment terms of the NSA. The NSA defines the QPA for a given item or service as generally the median contracted rate on January 31, 2019 for the same or similar item or service, increased for inflation.
Simple right? Not really. As you can imagine, the devil is in the details as to how the QPA is determined. Fortunately, in June 2022, CMS published a guide with the straightforward title, “Qualifying Payment Amount Calculation Methodology,” that does a pretty good job of explaining how to calculate the QPA. You can access that guide at: https://www.cms.gov/files/document/caaqualifying-payment-amount-calculation-methodology.pdf
This Guide addresses the terms that are defined in the NSA that relate to the QPA. For example, to calculate QPA for items/services furnished during 2022, you need to increase the median contracted rate as of January 31, 2019 by the percentage increase in the consumer price index for all urban consumers (U.S. city average) (“CPI–U”) over 2019, the percentage increase over 2020, and the percentage increase over 2021. Then, to calculate QPA for items/services furnished during 2023 or a subsequent year, the QPA for 2022 is then adjusted annually by the annual increase in the CPI–U.
Not exciting, but this is as practical a guide as you will find. So, keep it handy when the inevitable payment dispute arises and you want to make sure that the insurer has determined a QPA in a manner required by the regulations.
If you believe that there are factors that are not included in the QPA that are relevant to the items or services that you provided to the patient who is the subject of an NSA dispute, then you should also be aware of the NSA Dispute Resolution Regulations that were issued on August 19, 2022, that are intended to make certain medical claims payment processes more transparent for providers and clarify the process for providers and health insurance companies to resolve their disputes.
There is not much time left but if you want to learn more about the NSA, telemedicine, the Anti-Kickback Statute, the Stark law, the January 21, 2021 amendments to the regulations to those laws, the False Claims Act, and much more, we invite you to join Henry Casale, Dan Mulholland, and Mary Paterni in our “Hospital-Physician Contracts and Compliance Clinic” that will be held in Las Vegas, Nevada, from November 17-19, 2022. If you can’t catch us then, be sure to check the HortySpringer website for more information about new and upcoming opportunities on these topics.