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Urdu“Congress worked diligently to ensure the No Surprises Act protects patients from surprise medical bills but, at the same time, created a process that requires insurers to make reasonable payments to the physicians providing services to patients,” said ASA President Michael W. Champeau, M.D., FASA. “Anesthesiologists fully supported safeguarding patients through these benefits of the law, but we have grave concerns that the responsible federal agencies and insurers are failing to implement the law the way Congress intended.”
This flawed implementation has led to a significant imbalance that benefits insurance companies while harming physicians, especially small- and medium-sized community-based practices. For example, multiple practices nationwide have reported unresolved payment disputes for services provided 10 or 11 months ago. In other cases, insurance companies have slashed payments to anesthesiologists and other specialists by nearly 40%, forcing anesthesiologists out of health care networks.
If physicians aren’t paid fairly, the financial strain may cause some to close their doors or relocate to a part of the country where practicing their specialty is less expensive. And that means some patients may not be able to receive care at the nearest hospital, or may have to wait months for needed care, especially if they live in a small town or rural area. The same problem may arise in cities with a large population of patients who are covered by Medicare or Medicaid. This may delay their diagnosis and treatment if they have an illness or injury.
“The implementation of the No Surprises Act has empowered insurance companies to evade negotiating, and their stance is ‘take it or leave it.’ But we are confident we can fix this problem to ensure fair pay and sustainable community practices,” said Dr. Champeau. “As an anesthesiologist in a small practice, I experienced similar issues when California passed a balanced billing law and, at first, 100% of the payment dispute decisions went in favor of the insurance companies. Everyone recognized that was not right, nor good for patients. Ultimately, the law was changed, and we have seen a vast improvement in payments, allowing our practices to remain viable.”
The ASA letter to the CMS CCIIO describes nine challenges faced by anesthesiologists and provides specific recommendations to address them.
Among the most urgent:
Audit Payer QPAs
There are ongoing reports of payers using inaccurate qualifying payment amounts (QPAs), many of which are unreasonably low and inconsistent with most local in-network contract rates. ASA applauds the agency for its recent action to improve QPA accuracy by directing payers to halt the use of “phantom” payment rates and $0 rates in calculating QPA rates, an important first step in holding payers accountable for accurate QPAs. Payers’ past behavior should raise concerns with CMS about the accuracy of QPA calculations, and ASA recommends the agency immediately implement thorough and comprehensive audits of payer QPAs.
Lift Holds on Resolution Disputes
ASA has received numerous reports of independent dispute resolution (IDR) holds on anesthesia claims, with some practices reporting holds on hundreds of claims with no explanation regarding the delay. Some holds have been in place for 90 days or longer, and are significantly impacting anesthesiologists’ practices. ASA recommends CMS lift these holds as well as develop and implement guidance that improves the effectiveness and efficiency of the IDR process, ensuring that payment disputes are resolved expeditiously.
Improve Batching Rules
The CMS guidance continues a highly inefficient policy regarding the batching of anesthesia claims by limiting them to the same service facility, CPT code and payer. This prevents anesthesiologists from efficiently batching claims, exacerbating the problems related to the high volume of claims received by IDR entities. The ASA recommends CMS align their guidance with conventional anesthesia provider-payers contracting practices that are based upon an anesthesia conversion factor. Further, new guidance should permit batching of all anesthesia claims by the same payer, with the same anesthesia conversion factor in the same geographic area. This change would require payers to disclose the actual anesthesia conversion factor used to calculate the QPA.
Other recommendations include: improving the timeliness of the dispute resolution process; expediting payment disputes; directing IDR entities to give equal consideration to all factors listed in the law; developing guidance for IDR entities to investigate the status of missing items before rejecting the claim; mandating the use of existing Remittance Advice Remark Codes; modifying requirements for submission of data to include clear designations of plan types; and ensuring payer compliance with payment deadline rules and guidance.
THE AMERICAN SOCIETY OF ANESTHESIOLOGISTS
Founded in 1905, the American Society of Anesthesiologists (ASA) is an educational, research and scientific society with more than 56,000 members organized to raise and maintain the standards of the medical practice of anesthesiology. ASA is committed to ensuring physician anesthesiologists evaluate and supervise the medical care of patients before, during and after surgery to provide the highest quality and safest care every patient deserves.
For more information on the field of anesthesiology, visit the American Society of Anesthesiologists online at asahq.org. To learn more about the role physician anesthesiologists play in ensuring patient safety, visit asahq.org/MadeforThisMoment. Like ASA on Facebook, follow ASALifeline on Twitter.
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